Provider Demographics
NPI:1538670195
Name:INNATE UNIVERSE LLC
Entity type:Organization
Organization Name:INNATE UNIVERSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-861-6940
Mailing Address - Street 1:230 RIVERSTONE PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6414
Mailing Address - Country:US
Mailing Address - Phone:770-720-0099
Mailing Address - Fax:770-720-0002
Practice Address - Street 1:230 RIVERSTONE PKWY STE B
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6414
Practice Address - Country:US
Practice Address - Phone:770-720-0099
Practice Address - Fax:770-720-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-22
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty