1649670670 NPI number — PHYSICIANS CARE CENTERS OF LITHIA SPRINGS

Table of content: JONATHAN DEE BRADSHAW DPT,PT (NPI 1508413709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649670670 NPI number — PHYSICIANS CARE CENTERS OF LITHIA SPRINGS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS CARE CENTERS OF LITHIA SPRINGS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649670670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
870 CRESTMARK DR
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
LITHIA SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30122-2665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-398-8304
Provider Business Mailing Address Fax Number:
678-398-8305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
870 CRESTMARK DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LITHIA SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30122-2665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-398-8304
Provider Business Practice Location Address Fax Number:
678-398-8305
Provider Enumeration Date:
08/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STEELE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
561-385-0731

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1316957939 . This is a "OTHER NPI #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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