Provider Demographics
NPI:1194020412
Name:PHYSIO LAB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PHYSIO LAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:VICTOR LLOYD
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-919-6835
Mailing Address - Street 1:107 PEACOCK DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3637
Mailing Address - Country:US
Mailing Address - Phone:478-919-6835
Mailing Address - Fax:
Practice Address - Street 1:107 PEACOCK DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3637
Practice Address - Country:US
Practice Address - Phone:478-919-6835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORVIC GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty