Provider Demographics
NPI:1831205137
Name:INTEGRATIVE MEDICINE CENTER, PLLC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-253-1900
Mailing Address - Street 1:1318 JAMESTOWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3382
Mailing Address - Country:US
Mailing Address - Phone:757-253-1900
Mailing Address - Fax:757-253-2900
Practice Address - Street 1:1318 JAMESTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3382
Practice Address - Country:US
Practice Address - Phone:757-253-1900
Practice Address - Fax:757-253-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350001233Medicare PIN
VA350001219Medicare PIN
VAU75780Medicare UPIN
VAT21411Medicare UPIN
VAC08133Medicare PIN