Provider Demographics
NPI:1861219644
Name:JEFFERSONVILLE INTEGRATIVE CLINIC LLC
Entity type:Organization
Organization Name:JEFFERSONVILLE INTEGRATIVE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:KINZEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-761-1000
Mailing Address - Street 1:300 SPRING ST STE C
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3385
Mailing Address - Country:US
Mailing Address - Phone:501-223-2776
Mailing Address - Fax:501-223-2779
Practice Address - Street 1:300 SPRING ST STE 3C
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3385
Practice Address - Country:US
Practice Address - Phone:501-223-2776
Practice Address - Fax:501-223-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)