Integrated Life Center, Inc.

Primary specialty

Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X

License

025893 Issued in GA

Legal business name

INTEGRATED LIFE CENTER, INC.

Practice address

4641 Stonegate Industrial Blvd
Stone Mountain, GA 30083-1908

Phone

(404) 377-5556

Fax

(404) 292-9903

NPI assigned

Feb 8, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dennis Arthur O'Brien, M.D.

Title

Ceo

Phone

(404) 377-5556

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1321833600000",
    "number": "1427199199",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4641 STONEGATE INDUSTRIAL BLVD",
            "city": "STONE MOUNTAIN",
            "state": "GA",
            "postal_code": "300831908",
            "telephone_number": "404-377-5556",
            "fax_number": "404-292-0093"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4641 STONEGATE INDUSTRIAL BLVD",
            "city": "STONE MOUNTAIN",
            "state": "GA",
            "postal_code": "300831908",
            "telephone_number": "404-377-5556",
            "fax_number": "404-292-9903"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED LIFE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-08",
        "last_updated": "2011-11-21",
        "status": "A",
        "authorized_official_last_name": "O'BRIEN",
        "authorized_official_first_name": "DENNIS",
        "authorized_official_middle_name": "ARTHUR",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "404-377-5556",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "GA",
            "license": "025893",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00921324A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.