Provider Demographics
NPI:1073129441
Name:KOLL, IAN MICHAEL
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:KOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 LAKE FORREST DR STE 320
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3835
Mailing Address - Country:US
Mailing Address - Phone:404-255-6027
Mailing Address - Fax:404-255-4858
Practice Address - Street 1:6100 LAKE FORREST DR STE 320
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3835
Practice Address - Country:US
Practice Address - Phone:404-255-6027
Practice Address - Fax:404-255-4858
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010387111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIR010387OtherLICENSE NUMBER