Provider Demographics
NPI:1174745517
Name:IM, PHILLIP (CHIR 007185)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:CHIR 007185
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 N BERKELEY LAKE ROAD
Mailing Address - Street 2:D-126
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:678-571-7140
Mailing Address - Fax:470-709-2187
Practice Address - Street 1:2645 N BERKELEY LAKE RD NW # D-126
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3002
Practice Address - Country:US
Practice Address - Phone:678-571-7140
Practice Address - Fax:470-709-2187
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007185111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor