Provider Demographics
NPI:1831128578
Name:IMMUNE RECOVERY FOUNDATION LLC
Entity Type:Organization
Organization Name:IMMUNE RECOVERY FOUNDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:S. EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:770-455-6100
Mailing Address - Street 1:4646 N SHALLOWFORD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6304
Mailing Address - Country:US
Mailing Address - Phone:770-455-6100
Mailing Address - Fax:727-455-1999
Practice Address - Street 1:4646 N SHALLOWFORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6304
Practice Address - Country:US
Practice Address - Phone:770-455-6100
Practice Address - Fax:727-455-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7277Medicare ID - Type Unspecified