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General NPI Number Information
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NPI Number | 1114602281
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Entity Type | Organization
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Legal Business Name | INTEGRO CLINIC PLLC
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Dates
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Enumeration Date | 06/16/2023
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 6545 FRANCE AVE S STE 501
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City | EDINA
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State | MN
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Zip | 55435-2116
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Country | US
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Telephone | 612-428-4757
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Fax |
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Provider Business Mailing Address
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Address Line | 6013 KILLARNEY LN S
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City | EDINA
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State | MN
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Zip | 55436-1811
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Country | US
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Telephone | 614-817-8141
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Fax |
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Authorized Official
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Title or Position | MD/OWNER
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Name | ALFREDO A MASSA SUCCAR
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Credential | MD
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Telephone | 612-695-0949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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