Provider Demographics
NPI:1912392259
Name:INTEGRATIVE PHYSICAL MEDICINE OF DEBARY, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF DEBARY, LLC
Other - Org Name:INTEGRATIVE PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-488-3751
Mailing Address - Street 1:110 POND COURT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713
Mailing Address - Country:US
Mailing Address - Phone:386-753-7180
Mailing Address - Fax:386-753-7185
Practice Address - Street 1:110 POND COURT
Practice Address - Street 2:SUITE 300
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713
Practice Address - Country:US
Practice Address - Phone:386-753-7180
Practice Address - Fax:386-753-7185
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PHYSICAL MEDICINE HOLDING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty