Provider Demographics
NPI:1386120004
Name:INTEGRATIVE PHYSICAL MEDICINE OF SANFORD, LLC
Entity type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF SANFORD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-262-0082
Mailing Address - Street 1:425 ALEXANDRIA BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5548
Mailing Address - Country:US
Mailing Address - Phone:321-318-6758
Mailing Address - Fax:
Practice Address - Street 1:2676 S ORLANDO DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-5339
Practice Address - Country:US
Practice Address - Phone:321-262-0082
Practice Address - Fax:321-262-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty