Provider Demographics
NPI:1104223916
Name:INTEGRATIVE PHYSICAL MEDICINE OF MOUNT DORA LLC
Entity type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF MOUNT DORA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEUPLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-561-2361
Mailing Address - Street 1:2818 S BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6537
Mailing Address - Country:US
Mailing Address - Phone:352-561-2361
Mailing Address - Fax:352-561-2363
Practice Address - Street 1:2818 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726
Practice Address - Country:US
Practice Address - Phone:352-561-2361
Practice Address - Fax:352-561-2363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PHYSICAL MEDICINE HOLDING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-21
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7533480001Medicare NSC
IB461AMedicare PIN