Healthcare Provider Details

I. General information

NPI: 1780902502
Provider Name (Legal Business Name): INTEGRATIVE HEALTH CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6617 HERITAGE PKWY SUITE 100
ROCKWALL TX
75087-8750
US

IV. Provider business mailing address

6617 HERITAGE PKWY SUITE 100
ROCKWALL TX
75087-8750
US

V. Phone/Fax

Practice location:
  • Phone: 972-412-7555
  • Fax: 972-412-7558
Mailing address:
  • Phone: 972-412-7555
  • Fax: 972-412-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROBERT SUTHERLAND
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 972-414-7555