Provider Demographics
NPI:1619749702
Name:ATLAS INTEGRATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:ATLAS INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-366-3712
Mailing Address - Street 1:2405 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3019
Mailing Address - Country:US
Mailing Address - Phone:318-828-1517
Mailing Address - Fax:
Practice Address - Street 1:1939 SOUTHERN LOOP STE O
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8342
Practice Address - Country:US
Practice Address - Phone:318-536-3155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty