Healthcare Provider Details

I. General information

NPI: 1700708922
Provider Name (Legal Business Name): INTEGRATIVE LIFE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 CANYON AVE STE 2A
FORT COLLINS CO
80521-2686
US

IV. Provider business mailing address

814 W MOUNTAIN AVE
FORT COLLINS CO
80521-2508
US

V. Phone/Fax

Practice location:
  • Phone: 970-598-5012
  • Fax:
Mailing address:
  • Phone: 512-296-0319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHELLEY W MOORE
Title or Position: PHYSICIAN
Credential: MD
Phone: 512-296-0319