Provider Demographics
NPI:1093819450
Name:PROFESSIONAL THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL THERAPY SERVICES, LLC
Other - Org Name:PRO THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-7217
Mailing Address - Street 1:8823 PRODUCTION LANE
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:3640 MUNDY MILL RD STE 102B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-8226
Practice Address - Country:US
Practice Address - Phone:770-287-8821
Practice Address - Fax:770-287-8797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-06-04
Deactivation Date:2006-12-15
Deactivation Code:
Reactivation Date:2008-05-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116807Medicare Oscar/Certification