Healthcare Provider Details

I. General information

NPI: 1013364397
Provider Name (Legal Business Name): INTEGRATIVE MEDICAL GROUP, INC., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W 3RD ST STE 120A
LOS ANGELES CA
90057-5901
US

IV. Provider business mailing address

2200 W 3RD ST STE 120A
LOS ANGELES CA
90057-5901
US

V. Phone/Fax

Practice location:
  • Phone: 310-905-3331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN SPIVAK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-905-3331