Healthcare Provider Details

I. General information

NPI: 1548751746
Provider Name (Legal Business Name): INTEGRATIVE REHABILITATION MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 LAKE WASHINGTON RD
MELBOURNE FL
32934-7613
US

IV. Provider business mailing address

1515 MICHIGAN ST NE STE 115
GRAND RAPIDS MI
49503-2031
US

V. Phone/Fax

Practice location:
  • Phone: 616-690-2424
  • Fax: 616-825-6139
Mailing address:
  • Phone: 616-690-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: TODD PAUL O'DELL
Title or Position: OWNER/OPERATOR
Credential:
Phone: 616-690-2424