Healthcare Provider Details

I. General information

NPI: 1063768455
Provider Name (Legal Business Name): INTEGRACARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 W 29TH ST
GREELEY CO
80634-8399
US

IV. Provider business mailing address

PO BOX 65
EDWARDS CO
81632-0065
US

V. Phone/Fax

Practice location:
  • Phone: 970-353-6800
  • Fax: 970-506-4202
Mailing address:
  • Phone: 970-977-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY CAMERON WALLACE
Title or Position: MANAGER
Credential:
Phone: 970-977-6239