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General NPI Number Information
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NPI Number | 1972053866
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Entity Type | Organization
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Legal Business Name | INTEGRATED HEALTH CENTER OF GA, LLC
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Dates
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Enumeration Date | 10/04/2016
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Last Update Date | 11/08/2016
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Provider Practice Location Address
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Address Line | 1400 BUFORD HWY SUITE K2
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City | BUFORD
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State | GA
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Zip | 30518-8721
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Country | US
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Telephone | 470-326-5750
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 BUFORD HWY SUITE K2
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City | BUFORD
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State | GA
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Zip | 30518-8721
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Country | US
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Telephone | 470-326-5750
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. OTIS SAMUEL POWELL JR.
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Credential | M.D.
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Telephone | 470-326-5750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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