Provider Demographics
NPI:1124267281
Name:INTEGRATIVE MEDICINE CENTER. LLC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE CENTER. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:BASTRESS
Authorized Official - Suffix:II
Authorized Official - Credentials:LAC
Authorized Official - Phone:240-420-8625
Mailing Address - Street 1:1140 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5852
Mailing Address - Country:US
Mailing Address - Phone:240-420-8625
Mailing Address - Fax:240-420-8627
Practice Address - Street 1:1140 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5852
Practice Address - Country:US
Practice Address - Phone:240-420-8625
Practice Address - Fax:240-420-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00872171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty