Provider Demographics
NPI:1396052825
Name:INTEGRATIVE LIFE CENTER
Entity type:Organization
Organization Name:INTEGRATIVE LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-739-2276
Mailing Address - Street 1:1104 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-2305
Mailing Address - Country:US
Mailing Address - Phone:615-891-2226
Mailing Address - Fax:615-915-3813
Practice Address - Street 1:1104 16TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2305
Practice Address - Country:US
Practice Address - Phone:615-891-2226
Practice Address - Fax:615-915-3813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-03
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000006277261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health