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General NPI Number Information
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NPI Number | 1982599536
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Entity Type | Organization
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Legal Business Name | INTEGRATED SPECIALTY CLINIC LLC
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Dates
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Enumeration Date | 06/12/2025
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 26133 GILMORE WAY
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City | DAPHNE
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State | AL
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Zip | 36526-0079
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Country | US
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Telephone | 314-610-2277
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Fax |
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Provider Business Mailing Address
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Address Line | 26133 GILMORE WAY
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City | DAPHNE
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State | AL
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Zip | 36526-0079
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. MANDI JACKSON
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Credential | FNP-C
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Telephone | 314-610-2277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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