MEDICARE: INTEGRATED TMS 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336718204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED TMS LLC

Provider Business Mailing Address
First Line	:	1664 S DIXIE DR STE 102
Second Line	:	BLD E
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-7327
Country	:	US
Telephone Number	:	435-767-8840
Fax Number	:	435-703-6003

Provider Business Practice Location Address
First Line	:	1664 S DIXIE DR STE 102
Second Line	:	BLD E
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-7327
Country	:	US
Telephone Number	:	435-767-8840
Fax Number	:	435-703-6003

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	FORREST JIM WOLVERTON
Credential	:
Telephone Number	:	435-767-8840

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	06/28/2021

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