Provider Demographics
NPI:1346962701
Name:LONGLEAF PHYSICAL THERAPY, LLC.
Entity Type:Organization
Organization Name:LONGLEAF PHYSICAL THERAPY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:POMEROY
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:334-695-0993
Mailing Address - Street 1:1510 MILLPOND RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-7407
Mailing Address - Country:US
Mailing Address - Phone:334-695-0993
Mailing Address - Fax:
Practice Address - Street 1:311 N DAWSON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5132
Practice Address - Country:US
Practice Address - Phone:334-695-0993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
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
GA003183884AMedicaid