Provider Demographics
NPI:1114054343
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:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:M
Authorized Official - Last Name:YAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:334-396-2110
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:334-396-2110
Mailing Address - Fax:334-396-2115
Practice Address - Street 1:1899 LAKE RD
Practice Address - Street 2:SUITE 122
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2291
Practice Address - Country:US
Practice Address - Phone:770-943-1142
Practice Address - Fax:770-917-0926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PT SOLUTIONS OF ACWORTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-27
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6455Medicare PIN