Healthcare Provider Details

I. General information

NPI: 1770967663
Provider Name (Legal Business Name): INTEGRATIVE HEALTH CARE INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 PONCE DE LEON BLVD SUITE 102
CORAL GABLES FL
33134-7274
US

IV. Provider business mailing address

3211 PONCE DE LEON BLVD SUITE 102
CORAL GABLES FL
33134-7274
US

V. Phone/Fax

Practice location:
  • Phone: 305-443-3480
  • Fax: 305-443-3478
Mailing address:
  • Phone: 305-443-3480
  • Fax: 305-443-3478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARITZA FUENTES
Title or Position: AMBR
Credential:
Phone: 305-443-3480