Provider Demographics
NPI:1013388479
Name:ADVANCED INTEGRATED MEDICINE PLLC
Entity Type:Organization
Organization Name:ADVANCED INTEGRATED MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ALY KHYM
Authorized Official - Middle Name:BUENTIPO
Authorized Official - Last Name:ZARZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:210-599-9570
Mailing Address - Street 1:11465A TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3138
Mailing Address - Country:US
Mailing Address - Phone:210-599-9570
Mailing Address - Fax:210-599-9572
Practice Address - Street 1:11465A TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3138
Practice Address - Country:US
Practice Address - Phone:210-599-9570
Practice Address - Fax:210-599-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX468440Medicare PIN