Provider Demographics
NPI:1164071262
Name:GATE CITY INTEGRATIVE MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:GATE CITY INTEGRATIVE MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:336-860-1514
Mailing Address - Street 1:806 GREEN VALLEY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7076
Mailing Address - Country:US
Mailing Address - Phone:336-860-1514
Mailing Address - Fax:320-238-7190
Practice Address - Street 1:806 GREEN VALLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7076
Practice Address - Country:US
Practice Address - Phone:336-860-1514
Practice Address - Fax:320-238-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty