1174501100 NPI number — ORTHOSPORT PHYSICAL THERAPY LLC

Table of content: (NPI 1174501100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174501100 NPI number — ORTHOSPORT PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOSPORT PHYSICAL THERAPY 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:
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:
1174501100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 ACWORTH DUE WEST RD NW
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30144-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-974-7494
Provider Business Mailing Address Fax Number:
770-974-9141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 ACWORTH DUE WEST RD NW
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-974-7494
Provider Business Practice Location Address Fax Number:
770-974-9141
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHASTAIN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
FOUNDER AND CEO
Authorized Official Telephone Number:
770-974-7494

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  3909 , 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: 393730 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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