Healthcare Provider Details

I. General information

NPI: 1568919421
Provider Name (Legal Business Name): INJURED WORKERS ASSISTANCE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 PHOENIX BLVD SUITE 5
COLLEGE PARK GA
30349-5554
US

IV. Provider business mailing address

1657 PHOENIX BLVD SUITE 5
COLLEGE PARK GA
30349-5554
US

V. Phone/Fax

Practice location:
  • Phone: 713-539-8175
  • Fax:
Mailing address:
  • Phone: 713-539-8175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WINSTON TOLLETT
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 713-539-8175