Provider Demographics
NPI:1417593047
Name:INTEGRATIVE MEDICAL GROUP AND MEDICAL SPA, INC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICAL GROUP AND MEDICAL SPA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER-CADRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-463-1719
Mailing Address - Street 1:805 LAMBERT DR NE STE C
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4189
Mailing Address - Country:US
Mailing Address - Phone:678-561-3023
Mailing Address - Fax:
Practice Address - Street 1:805 LAMBERT DR NE STE C
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-4189
Practice Address - Country:US
Practice Address - Phone:678-561-3023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care