Provider Demographics
NPI:1417048885
Name:WEST COBB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WEST COBB PHYSICAL THERAPY
Other - Org Name:VENTURE PHYSICAL THERAPY WEST COBB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTORE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DARIN
Authorized Official - Last Name:DURELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-425-2151
Mailing Address - Street 1:5041 DALLAS HWY STE C
Mailing Address - Street 2:BUILDING 1 SUITE C
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6458
Mailing Address - Country:US
Mailing Address - Phone:770-425-2151
Mailing Address - Fax:770-425-5982
Practice Address - Street 1:5041 DALLAS HWY STE C
Practice Address - Street 2:BUILDING 1 SUITE C
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6458
Practice Address - Country:US
Practice Address - Phone:770-425-2151
Practice Address - Fax:770-425-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty