1083162978 NPI number — INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083162978 NPI number — INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT PHYSICAL THERAPY OF GA, LLC
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:
6
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:
1083162978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8823 PRODUCTION LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OOLTEWAH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37363-6511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 CANAL ST
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
POOLER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31322-4095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-330-8444
Provider Business Practice Location Address Fax Number:
912-330-8844
Provider Enumeration Date:
09/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JOHANNESON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF REVENUE
Authorized Official Telephone Number:
423-238-3220

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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