Healthcare Provider Details

I. General information

NPI: 1164331294
Provider Name (Legal Business Name): ORTHO INTEGRATIVE MEDICINE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25749 US HIGHWAY 19 N STE 100
CLEARWATER FL
33763-2004
US

IV. Provider business mailing address

25749 US HIGHWAY 19 N STE 100
CLEARWATER FL
33763-2004
US

V. Phone/Fax

Practice location:
  • Phone: 239-260-0530
  • Fax:
Mailing address:
  • Phone: 239-260-0530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHANELE SMITH
Title or Position: MANAGER
Credential:
Phone: 239-260-0530