Provider Demographics
NPI:1336505809
Name:INTEGRATED HEALTH CENTER CORP
Entity Type:Organization
Organization Name:INTEGRATED HEALTH CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-765-2733
Mailing Address - Street 1:950 SCALES RD STE 403
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4342
Mailing Address - Country:US
Mailing Address - Phone:678-765-2733
Mailing Address - Fax:
Practice Address - Street 1:8600 TARA BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:678-834-7615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGAMedicaid