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General NPI Number Information
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NPI Number | 1104223916
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE PHYSICAL MEDICINE OF MOUNT DORA LLC
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Dates
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Enumeration Date | 11/21/2014
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Last Update Date | 09/28/2018
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Provider Practice Location Address
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Address Line | 2818 S BAY ST
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City | EUSTIS
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State | FL
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Zip | 32726
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Country | US
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Telephone | 352-561-2361
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Fax | 352-561-2363
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Provider Business Mailing Address
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Address Line | 2818 S BAY ST
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City | EUSTIS
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State | FL
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Zip | 32726-6537
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Country | US
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Telephone | 352-561-2361
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Fax | 352-561-2363
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Authorized Official
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Title or Position | OWNER
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Name | BRET SCHEUPLEIN
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Credential |
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Telephone | 352-561-2361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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