Provider Demographics
NPI:1871823203
Name:INTEGRATIVE MEDICINE CLINIC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICINE CLINIC
Other - Org Name:SYMBIOTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-390-1397
Mailing Address - Street 1:PO BOX 5379
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631
Mailing Address - Country:US
Mailing Address - Phone:970-328-2044
Mailing Address - Fax:970-328-0346
Practice Address - Street 1:960 CHAMBERS AVE
Practice Address - Street 2:A-203
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-328-2044
Practice Address - Fax:970-328-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96554347Medicaid
COH54319Medicare UPIN