Provider Demographics
NPI:1356905327
Name:THRIVE INTEGRATED MEDICAL, LLC
Entity type:Organization
Organization Name:THRIVE INTEGRATED MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-968-3500
Mailing Address - Street 1:6534 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4022
Mailing Address - Country:US
Mailing Address - Phone:813-968-3500
Mailing Address - Fax:813-968-3555
Practice Address - Street 1:6534 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-968-3500
Practice Address - Fax:813-968-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003466000Medicaid