Healthcare Provider Details

I. General information

NPI: 1083057434
Provider Name (Legal Business Name): INTEGRATIVE BODY HEALTH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 S PARK ST SUITE 102
CARROLLTON GA
30117-3825
US

IV. Provider business mailing address

775 S PARK ST SUITE 102
CARROLLTON GA
30117-3825
US

V. Phone/Fax

Practice location:
  • Phone: 770-832-1640
  • Fax: 770-832-1649
Mailing address:
  • Phone: 770-832-1640
  • Fax: 770-832-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR008718
License Number StateGA

VIII. Authorized Official

Name: DR. CLYDE EMIR NAVARRO
Title or Position: PRESIDENT
Credential: D.C.
Phone: 678-485-3155