MEDICARE: ASPIRE INTEGRATIVE HEALTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	DO. 1492	AL

General Provider Information

NPI Number	:	1225491426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASPIRE INTEGRATIVE HEALTH CLINIC

Provider Business Mailing Address
First Line	:	2202 GATEWAY DR STE D
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36801-6870
Country	:	US
Telephone Number	:	334-203-1723
Fax Number	:

Provider Business Practice Location Address
First Line	:	2202 GATEWAY DR STE D
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36801-6870
Country	:	US
Telephone Number	:	334-203-1723
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VIENGXAY MALAVONG
Credential	:	DO
Telephone Number	:	334-203-1723

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	04/04/2016

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