Provider Demographics
NPI:1184796153
Name:INTEGRATED MANAGEMENT PROFESSIONAL INC.
Entity type:Organization
Organization Name:INTEGRATED MANAGEMENT PROFESSIONAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:AMY
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN, RPT
Authorized Official - Phone:973-228-8548
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-0042
Mailing Address - Country:US
Mailing Address - Phone:973-228-8548
Mailing Address - Fax:973-228-7716
Practice Address - Street 1:101 ROSELAND AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5903
Practice Address - Country:US
Practice Address - Phone:973-228-8548
Practice Address - Fax:973-228-7716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00024400171100000X
NJ41YS00321100235Z00000X
NJ46TR00176500261QX0100X
225X00000X, 225100000X, 235Z00000X, 171100000X
NJ40QA00409000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJGO166781Medicare ID - Type Unspecified