Provider Demographics
NPI:1932620796
Name:INTEGRATIVE GERIATRICS, PLLC
Entity Type:Organization
Organization Name:INTEGRATIVE GERIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CNP
Authorized Official - Phone:612-308-2162
Mailing Address - Street 1:21897 S DIAMOND LAKE RD STE 400-403
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4642
Mailing Address - Country:US
Mailing Address - Phone:763-317-1122
Mailing Address - Fax:
Practice Address - Street 1:21897 S DIAMOND LAKE RD STE 400-403
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4642
Practice Address - Country:US
Practice Address - Phone:763-317-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty