Provider Demographics
NPI:1144741976
Name:PROVISION PHYSICAL THERAPY,LLC
Entity Type:Organization
Organization Name:PROVISION PHYSICAL THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VENILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:404-692-1654
Mailing Address - Street 1:105 COMMERCE DR STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7352
Mailing Address - Country:US
Mailing Address - Phone:404-692-1654
Mailing Address - Fax:404-393-4044
Practice Address - Street 1:105 COMMERCE DR STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7352
Practice Address - Country:US
Practice Address - Phone:404-692-1654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-01
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0095502081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty