Provider Demographics
NPI:1235945346
Name:INTEGRATIVE MEDICINE LAKE COUNTRY, LLC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE LAKE COUNTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:262-256-3020
Mailing Address - Street 1:138 NORTH AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1725
Mailing Address - Country:US
Mailing Address - Phone:262-256-3020
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH AVE STE 4
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1725
Practice Address - Country:US
Practice Address - Phone:262-256-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty