Healthcare Provider Details

I. General information

NPI: 1164071262
Provider Name (Legal Business Name): GATE CITY INTEGRATIVE MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-7076
US

IV. Provider business mailing address

806 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-7076
US

V. Phone/Fax

Practice location:
  • Phone: 336-860-1514
  • Fax: 320-238-7190
Mailing address:
  • Phone: 336-860-1514
  • Fax: 320-238-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGELA JOHNSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: FNP-BC
Phone: 336-860-1514