Provider Demographics
NPI:1174501100
Name:ORTHOSPORT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ORTHOSPORT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-974-7494
Mailing Address - Street 1:3450 ACWORTH DUE WEST RD NW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1001
Mailing Address - Country:US
Mailing Address - Phone:770-974-7494
Mailing Address - Fax:770-974-9141
Practice Address - Street 1:3450 ACWORTH DUE WEST RD NW
Practice Address - Street 2:SUITE 310
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-974-7494
Practice Address - Fax:770-974-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3909261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA393730OtherBLUE CROSS BLUE SHIELD
GAGRP8131Medicare PIN
GA116838Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER