Healthcare Provider Details

I. General information

NPI: 1225650435
Provider Name (Legal Business Name): ICEBERG HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 MCKENDREE CHURCH RD STE 400B
LAWRENCEVILLE GA
30043-4100
US

IV. Provider business mailing address

1670 MCKENDREE CHURCH RD STE 400B
LAWRENCEVILLE GA
30043-4100
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-0444
  • Fax: 470-823-9759
Mailing address:
  • Phone: 678-985-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: KAMLESH PATEL
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 678-985-0444