Organization Name: | INTEGRATED MEDICINE GROUP LLC |
NPI Number: | 1679508212 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | CHRISTY HEITSCH (CLINIC DIRECTOR) |
Mailing Address: | 163 Ne 102nd Ave Bldg V Portland |
State: | OR US |
Postal Code: | 972204169 |
Phone Number: | 5032573327 |
Fax Number: | 5032573374 |
NPI Enumeration Date: | 07/12/2006 |
NPI Last Update Date: | 01/22/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | MD11610 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | OR |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |