Provider Demographics
NPI:1326403361
Name:PHYSIO
Entity Type:Organization
Organization Name:PHYSIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,MHS
Authorized Official - Phone:678-459-7792
Mailing Address - Street 1:100 MOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2434
Mailing Address - Country:US
Mailing Address - Phone:770-889-2163
Mailing Address - Fax:770-889-4385
Practice Address - Street 1:100 MOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2434
Practice Address - Country:US
Practice Address - Phone:770-889-2163
Practice Address - Fax:770-889-4385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0121732251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty