Provider Demographics
NPI:1588782346
Name:PROHEALTH INTEGRATED MEDICAL
Entity type:Organization
Organization Name:PROHEALTH INTEGRATED MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-513-0111
Mailing Address - Street 1:1431 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5946
Mailing Address - Country:US
Mailing Address - Phone:770-513-0111
Mailing Address - Fax:770-513-3731
Practice Address - Street 1:1431 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5946
Practice Address - Country:US
Practice Address - Phone:770-513-0111
Practice Address - Fax:770-513-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005026111N00000X
GA016356173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1841244175OtherNPI NUMBER
GA1841233905OtherNPI NUMBER