Healthcare Provider Details

I. General information

NPI: 1083727994
Provider Name (Legal Business Name): INTEGRATED MEDICINE AND CHIROPRACTIC REGENERATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 JAMES SANDERS BLVD SUITE A
PADUCAH KY
42001-8401
US

IV. Provider business mailing address

2725 JAMES SANDERS BLVD SUITE A
PADUCAH KY
42001-8401
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-5114
  • Fax: 270-554-5021
Mailing address:
  • Phone: 270-554-5114
  • Fax: 270-554-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5134
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number36051
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002302
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JASON W BRAME
Title or Position: MANAGEMENT
Credential: DC
Phone: 270-554-5114