Provider Demographics
NPI:1376653899
Name:POITEVINT, THAD (PT,CSCS)
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:
Last Name:POITEVINT
Suffix:
Gender:M
Credentials:PT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 HIGHWAY 29 N
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1031
Mailing Address - Country:US
Mailing Address - Phone:770-683-6904
Mailing Address - Fax:
Practice Address - Street 1:2280 HIGHWAY 29 N
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1031
Practice Address - Country:US
Practice Address - Phone:770-683-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200732731OtherNATIONAL STRENGTH & CONDITIONING ASSOCIATION