Provider Demographics
NPI:1043766975
Name:ATHLETIC EDGE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ATHLETIC EDGE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:WHITWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-790-9798
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 ADAMS ST STE A
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408
Practice Address - Country:US
Practice Address - Phone:423-402-0778
Practice Address - Fax:186-633-4026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10299261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation