Healthcare Provider Details

I. General information

NPI: 1104154913
Provider Name (Legal Business Name): INTEGRATED CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E HJELLEN DRIVE
WASILLA AK
99654
US

IV. Provider business mailing address

PO BOX 773313
EAGLE RIVER AK
99577-3313
US

V. Phone/Fax

Practice location:
  • Phone: 907-696-1654
  • Fax: 907-696-3654
Mailing address:
  • Phone: 907-696-1654
  • Fax: 907-696-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number380
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier380
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerAK STATE LICENSE
# 2
Identifier1881735967
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: MICHAEL T UNDERWOOD
Title or Position: AGENT
Credential: BBA
Phone: 907-696-1654