=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629420260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA INTEGRATIVE MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2016
-----------------------------------------------------
Last Update Date | 07/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1891 HOWELL MILL RD NW SUITE B
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-515-0688
-----------------------------------------------------
Fax | 404-249-8230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1891 HOWELL MILL RD NW SUITE B
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-515-0688
-----------------------------------------------------
Fax | 404-249-8230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | MR. THINH NGUYEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 678-515-0688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 62402
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------