Provider Demographics
NPI:1083895973
Name:PT SOLUTIONS OF ACWORTH LLC
Entity Type:Organization
Organization Name:PT SOLUTIONS OF ACWORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-852-1692
Mailing Address - Street 1:PO BOX 242278
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2278
Mailing Address - Country:US
Mailing Address - Phone:334-396-3273
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:9390 THE LANDING DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-852-1692
Practice Address - Fax:770-852-1694
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PT SOLUTIONS OF ACWORTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-19
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6455Medicare PIN