MEDICARE: INTEGRATIVE HEALTH 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1811140056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE HEALTH LLC

Provider Business Mailing Address
First Line	:	7305 HANCOCK VILLAGE DR # 118
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-2771
Country	:	US
Telephone Number	:	804-399-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	15521 MIDLOTHIAN TPKE STE 402
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-7313
Country	:	US
Telephone Number	:	804-399-0002
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JACKYE KIM
Credential	:	DC
Telephone Number	:	804-399-0002

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	12/12/2019

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