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General NPI Number Information
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NPI Number | 1831128578
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Entity Type | Organization
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Legal Business Name | IMMUNE RECOVERY FOUNDATION LLC
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4646 N SHALLOWFORD RD SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30338-6304
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Country | US
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Telephone | 770-455-6100
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Fax | 727-455-1999
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Provider Business Mailing Address
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Address Line | 4646 N SHALLOWFORD RD SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30338-6304
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Country | US
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Telephone | 770-455-6100
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Fax | 727-455-1999
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Authorized Official
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Title or Position | OWNER
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Name | S. EDWARD BRADFORD
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Credential | P.A.
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Telephone | 770-455-6100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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