Healthcare Provider Details

I. General information

NPI: 1720639461
Provider Name (Legal Business Name): ICEBERG HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
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: 678-878-2330
Mailing address:
  • Phone: 678-985-0444
  • Fax: 678-878-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TONYA CULP
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential: CMRS
Phone: 770-971-8115