Provider Demographics
NPI:1427199199
Name:INTEGRATED LIFE CENTER, INC.
Entity type:Organization
Organization Name:INTEGRATED LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-377-5556
Mailing Address - Street 1:4641 STONEGATE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1908
Mailing Address - Country:US
Mailing Address - Phone:404-377-5556
Mailing Address - Fax:404-292-0093
Practice Address - Street 1:4641 STONEGATE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-1908
Practice Address - Country:US
Practice Address - Phone:404-377-5556
Practice Address - Fax:404-292-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025893320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00921324AMedicaid
GA00921324AMedicaid