MEDICARE: KT INTEGRATIVE MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1083276992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KT INTEGRATIVE MEDICINE LLC

Provider Business Mailing Address
First Line	:	2824 N POWER RD # 113-471
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-1672
Country	:	US
Telephone Number	:	480-571-3060
Fax Number	:	480-571-3061

Provider Business Practice Location Address
First Line	:	633 E RAY RD STE 131
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4206
Country	:	US
Telephone Number	:	480-571-3060
Fax Number	:	480-571-3061

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ANNETTE ALTAMIRANO LUSKO
Credential	:	DO
Telephone Number	:	480-571-3060

Provider Enumeration Date	:	07/01/2019
Last Update Date	:	07/01/2019

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