MEDICARE: INTEGRATED HEALTHCARE ASSOCIATES 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	363LF0000X	Family Nurse Practitioner	APRN.CNP.019584	OH

General Provider Information

NPI Number	:	1407399090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED HEALTHCARE ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	PO BOX 132
Second Line	:
City	:	ATHENS
State	:	OH
Zip	:	45701-0132
Country	:	US
Telephone Number	:	800-321-8293
Fax Number	:	844-623-7178

Provider Business Practice Location Address
First Line	:	5 CHARLES ST
Second Line	:
City	:	ATHENS
State	:	OH
Zip	:	45701-2329
Country	:	US
Telephone Number	:	800-321-8293
Fax Number	:

Authorized Official
Title or Position	:	PROJECT MANAGER - BILLING
Name	:	JACLYN M WILSON
Credential	:
Telephone Number	:	740-258-6480

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	11/30/2016

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