Provider Demographics
NPI:1760848980
Name:SOUTH ATLANTA INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:SOUTH ATLANTA INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-452-9931
Mailing Address - Street 1:1240 HIGHWAY 54 W
Mailing Address - Street 2:BUILDING 700, SUITE 700
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4557
Mailing Address - Country:US
Mailing Address - Phone:404-452-9931
Mailing Address - Fax:
Practice Address - Street 1:1240 HIGHWAY 54 W
Practice Address - Street 2:BUILDING 700, SUITE 700
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4557
Practice Address - Country:US
Practice Address - Phone:404-452-9931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty