Healthcare Provider Details

I. General information

NPI: 1376159178
Provider Name (Legal Business Name): INTEGRA THERAPEUTIC MASSAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 WELLS RD STE 300
ORANGE PARK FL
32073-2350
US

IV. Provider business mailing address

8257 SEVEN MILE DR
PONTE VEDRA BEACH FL
32082-3132
US

V. Phone/Fax

Practice location:
  • Phone: 904-612-4588
  • Fax: 904-260-3011
Mailing address:
  • Phone: 904-612-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DARLENE TAN
Title or Position: ADMINISTRATOR
Credential: ESQ
Phone: 904-612-4588