Provider Demographics
NPI:1114459096
Name:PREVENTIVE MEDICINE ANTI-AGING AND CHELATION THERAPY INC.
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ANTI-AGING AND CHELATION THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-891-1200
Mailing Address - Street 1:148 COBB PKWY
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-8566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:171 MOUNT PARAN RD NE
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-2211
Practice Address - Country:US
Practice Address - Phone:706-891-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service