Healthcare Provider Details

I. General information

NPI: 1477877330
Provider Name (Legal Business Name): INTEGRATED HEALING CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10549 N FLORIDA AVE SUITE I
TAMPA FL
33612-6707
US

IV. Provider business mailing address

10549 N FLORIDA AVE SUITE I
TAMPA FL
33612-6707
US

V. Phone/Fax

Practice location:
  • Phone: 813-402-2832
  • Fax: 813-402-2833
Mailing address:
  • Phone: 813-402-2832
  • Fax: 813-402-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMER FADDA
Title or Position: OWNER
Credential: AP
Phone: 813-402-2832