1497360010 NPI number — WALTER BROOKS III PT, DPT

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 1497360010 NPI number — WALTER BROOKS III PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
WALTER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

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:
1497360010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1765 OLD WEST BROAD ST BLDG 2-200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-549-1663
Provider Business Mailing Address Fax Number:
706-546-8792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3440 HIGHWAY 81
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30052-9112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-554-5009
Provider Business Practice Location Address Fax Number:
706-546-8792
Provider Enumeration Date:
09/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT015127 , 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: 14965223 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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