Healthcare Provider Details

I. General information

NPI: 1972379741
Provider Name (Legal Business Name): ORTHO INTEGRATIVE MEDICINE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
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: 855-724-6727
  • Fax:
Mailing address:
  • Phone: 855-724-6727
  • 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 Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EMMETT A. BLAHNIK
Title or Position: OWNER
Credential: DC
Phone: 608-358-8455