MEDICARE: INTEGRATION THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	2509	NM

General Provider Information

NPI Number	:	1255714226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATION THERAPY, LLC

Provider Business Mailing Address
First Line	:	1012 MARQUEZ PL
Second Line	:	SUITE 101B
City	:	SANTA FE
State	:	NM
Zip	:	87505-1834
Country	:	US
Telephone Number	:	505-780-8783
Fax Number	:	505-780-8794

Provider Business Practice Location Address
First Line	:	TREASURY CENTER 10
Second Line	:	CRESTED BUTTE WAY STE L2
City	:	MT. CRESTED BUTTE
State	:	CO
Zip	:	81225-0154
Country	:	US
Telephone Number	:	970-251-5462
Fax Number	:	970-251-5463

Authorized Official
Title or Position	:	OWNER
Name	:	JODI MEDELL
Credential	:	DPT
Telephone Number	:	505-780-8783

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	02/25/2021

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