Provider Demographics
NPI:1346855160
Name:MELTDOWN FITNESS ATLANTA, LLC
Entity Type:Organization
Organization Name:MELTDOWN FITNESS ATLANTA, LLC
Other - Org Name:REHAB AND BEYOND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANFORD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-899-6364
Mailing Address - Street 1:2250 OAK RD UNIT 815
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1905
Mailing Address - Country:US
Mailing Address - Phone:833-887-3422
Mailing Address - Fax:
Practice Address - Street 1:3983 LAVISTA RD STE 128
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5151
Practice Address - Country:US
Practice Address - Phone:833-887-3422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2021-11-23
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
PENDINGOtherAETNA