Provider Demographics
NPI:1912080953
Name:INTEGRATED REHABILITATION MEDICAL CORP
Entity Type:Organization
Organization Name:INTEGRATED REHABILITATION MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:661-267-6876
Mailing Address - Street 1:819 AUTO CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551
Mailing Address - Country:US
Mailing Address - Phone:661-267-6876
Mailing Address - Fax:661-538-9438
Practice Address - Street 1:819 AUTO CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551
Practice Address - Country:US
Practice Address - Phone:661-267-6876
Practice Address - Fax:661-538-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty