Provider Demographics
NPI:1376079772
Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Other - Org Name:BENCHMARK PT - PORT WENTWORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-3220
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7938 GA HIGHWAY 21
Practice Address - Street 2:STE 300
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-9807
Practice Address - Country:US
Practice Address - Phone:912-965-0601
Practice Address - Fax:912-965-0603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty