Provider Demographics
NPI:1922519743
Name:INTEGRATIVE HEALING SPA LLC
Entity Type:Organization
Organization Name:INTEGRATIVE HEALING SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GILBO
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:315-343-9900
Mailing Address - Street 1:3 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1803
Mailing Address - Country:US
Mailing Address - Phone:315-343-9900
Mailing Address - Fax:
Practice Address - Street 1:3 4TH AVE
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1803
Practice Address - Country:US
Practice Address - Phone:315-343-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013994-1261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center