Healthcare Provider Details

I. General information

NPI: 1821669854
Provider Name (Legal Business Name): INTEGRATIVE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10528 COLDWATER RD
FORT WAYNE IN
46845-1268
US

IV. Provider business mailing address

10528 COLDWATER RD
FORT WAYNE IN
46845-1268
US

V. Phone/Fax

Practice location:
  • Phone: 260-338-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL MILLER
Title or Position: OWNER
Credential:
Phone: 260-338-1700