Provider Demographics
NPI:1295131712
Name:INTEGRA HOME DOCTORS, INC.
Entity type:Organization
Organization Name:INTEGRA HOME DOCTORS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:LEONG
Authorized Official - Last Name:MANGUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-791-9340
Mailing Address - Street 1:16165 N 83RD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5816
Mailing Address - Country:US
Mailing Address - Phone:623-888-3014
Mailing Address - Fax:
Practice Address - Street 1:16165 N 83RD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5816
Practice Address - Country:US
Practice Address - Phone:623-888-3014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty