Provider Demographics
NPI:1184377285
Name:INTEGRATIVE AMD HOLISTIC CENTER, LLC
Entity type:Organization
Organization Name:INTEGRATIVE AMD HOLISTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHIBALD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-923-3290
Mailing Address - Street 1:375 N MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1278
Mailing Address - Country:US
Mailing Address - Phone:801-923-3290
Mailing Address - Fax:
Practice Address - Street 1:375 N MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1278
Practice Address - Country:US
Practice Address - Phone:801-923-3290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health