Healthcare Provider Details

I. General information

NPI: 1619946241
Provider Name (Legal Business Name): INTEGRATED MEDICAL CENTRE OF BONITA SPRINGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28315 S TAMIAMI TRAIL SUITE 101
BONITA SPRINGS FL
34134
US

IV. Provider business mailing address

28315 S TAMIAMI TRAIL SUITE 101
BONITA SPRINGS FL
34134
US

V. Phone/Fax

Practice location:
  • Phone: 239-947-1177
  • Fax: 239-947-6399
Mailing address:
  • Phone: 239-947-1177
  • Fax: 239-947-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH0005999
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCH0005870
License Number StateFL

VIII. Authorized Official

Name: MR. GARY L GENDRON
Title or Position: OWNER CLINIC DIRECTOR
Credential: DC
Phone: 239-947-1177