MEDICARE: INTEGRATIVE PHYSICAL MEDICINE OF LEESBURG, 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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1487112173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE PHYSICAL MEDICINE OF LEESBURG, LLC

Provider Business Mailing Address
First Line	:	425 ALEXANDRIA BLVD STE 1000
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-5548
Country	:	US
Telephone Number	:	321-318-6758
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 W NORTH BLVD STE 101
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-5039
Country	:	US
Telephone Number	:	321-318-6758
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARC OTT
Credential	:	DC
Telephone Number	:	352-702-4250

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	08/12/2019

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