Provider Demographics
NPI:1083936074
Name:STARTING BLOCK SPORTS MEDICINE & REHABILITATION
Entity Type:Organization
Organization Name:STARTING BLOCK SPORTS MEDICINE & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DC, ATC
Authorized Official - Phone:678-436-5866
Mailing Address - Street 1:105 SMOKE HILL LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7364
Mailing Address - Country:US
Mailing Address - Phone:678-436-5866
Mailing Address - Fax:678-262-3677
Practice Address - Street 1:105 SMOKE HILL LN
Practice Address - Street 2:SUITE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7364
Practice Address - Country:US
Practice Address - Phone:678-436-5866
Practice Address - Fax:678-262-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO008613111N00000X
GAPT0051292251S0007X
GAAT0012132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty