Provider Demographics
NPI:1669908836
Name:INTEGRATIVE PHYSICAL MEDICINE OF LAKELAND LLC
Entity type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF LAKELAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-977-3434
Mailing Address - Street 1:1205 EAST MAGNOLIA ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801
Mailing Address - Country:US
Mailing Address - Phone:863-272-7454
Mailing Address - Fax:863-272-7456
Practice Address - Street 1:1205 EAST MAGNOLIA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801
Practice Address - Country:US
Practice Address - Phone:863-272-7454
Practice Address - Fax:863-272-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty