Provider Demographics
NPI:1649623240
Name:INTEGRATIVE SPINE CARE LLC
Entity type:Organization
Organization Name:INTEGRATIVE SPINE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLANKI
Authorized Official - Suffix:
Authorized Official - Credentials:B SC
Authorized Official - Phone:314-469-7246
Mailing Address - Street 1:13710 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2602
Mailing Address - Country:US
Mailing Address - Phone:314-469-7246
Mailing Address - Fax:314-469-7251
Practice Address - Street 1:13710 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2602
Practice Address - Country:US
Practice Address - Phone:314-469-7246
Practice Address - Fax:314-469-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103749261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF97488Medicare UPIN