Provider Demographics
NPI:1962701722
Name:INDIVIDUALIZED MEDICINE, LLC
Entity type:Organization
Organization Name:INDIVIDUALIZED MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALYKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-329-3939
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-0100
Mailing Address - Country:US
Mailing Address - Phone:386-329-3939
Mailing Address - Fax:386-329-8990
Practice Address - Street 1:6100 SAINT JOHNS AVE
Practice Address - Street 2:SUITE 4(D)
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3844
Practice Address - Country:US
Practice Address - Phone:386-329-3939
Practice Address - Fax:386-329-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-19
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH08673Medicare UPIN
FL49324WMedicare PIN