Provider Demographics
NPI:1679990881
Name:INTEGRAL MEDICAL MASSAGE LLC
Entity type:Organization
Organization Name:INTEGRAL MEDICAL MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOMMARITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-369-6033
Mailing Address - Street 1:393 ADAMS CT
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2423
Mailing Address - Country:US
Mailing Address - Phone:248-369-6033
Mailing Address - Fax:248-282-8581
Practice Address - Street 1:393 ADAMS CT
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2423
Practice Address - Country:US
Practice Address - Phone:248-369-6033
Practice Address - Fax:248-282-8581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000983225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679990881OtherNPI TYPE 1