Healthcare Provider Details

I. General information

NPI: 1982919395
Provider Name (Legal Business Name): INTEGRACARE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH 2ND STREET
SARTELL MN
56377
US

IV. Provider business mailing address

100 SOUTH 2ND STREET
SARTELL MN
56377
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2600
  • Fax: 320-251-4763
Mailing address:
  • Phone: 320-251-2600
  • Fax: 320-251-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1491
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1491
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1491
License Number StateMN

VIII. Authorized Official

Name: MR. MARK RANDY HALSTROM
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 320-251-2600