Provider Demographics
NPI:1912578550
Name:INTEGRATED MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL GROUP LLC
Other - Org Name:DETRAY CHIROPRACTIC CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-785-4215
Mailing Address - Street 1:210 LATCHAW DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4315
Mailing Address - Country:US
Mailing Address - Phone:419-785-4215
Mailing Address - Fax:419-785-4274
Practice Address - Street 1:210 LATCHAW DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4315
Practice Address - Country:US
Practice Address - Phone:419-785-4215
Practice Address - Fax:419-785-4274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty