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General NPI Number Information
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NPI Number | 1376159178
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Entity Type | Organization
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Legal Business Name | INTEGRA THERAPEUTIC MASSAGE, LLC
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Dates
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Enumeration Date | 09/17/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 1871 WELLS RD STE 300
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City | ORANGE PARK
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State | FL
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Zip | 32073-2350
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Country | US
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Telephone | 904-612-4588
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Fax | 904-260-3011
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Provider Business Mailing Address
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Address Line | 8257 SEVEN MILE DR
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-3132
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Country | US
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Telephone | 904-612-4588
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. DARLENE TAN
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Credential | ESQ
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Telephone | 904-612-4588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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