Healthcare Provider Details

I. General information

NPI: 1144821323
Provider Name (Legal Business Name): INTEGRA CLINICAL SERVICES, LLC-GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RIVERSIDE PKWY SW
AUSTELL GA
30168-7749
US

IV. Provider business mailing address

8063 WESTSIDE BLVD
FULTON MD
20759-2464
US

V. Phone/Fax

Practice location:
  • Phone: 844-856-9355
  • Fax: 844-856-9355
Mailing address:
  • Phone: 844-856-9355
  • Fax: 844-856-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC NIXON
Title or Position: OWNER
Credential:
Phone: 844-856-9355