Provider Demographics
NPI:1417091372
Name:THE CANTRELL CENTER FOR PHYSICAL THERAPY AND SPORTS MEDICINE, P.C.
Entity Type:Organization
Organization Name:THE CANTRELL CENTER FOR PHYSICAL THERAPY AND SPORTS MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:MPT
Authorized Official - Phone:478-953-3535
Mailing Address - Street 1:405 OSIGIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8958
Mailing Address - Country:US
Mailing Address - Phone:478-953-3535
Mailing Address - Fax:
Practice Address - Street 1:405 OSIGIAN BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8958
Practice Address - Country:US
Practice Address - Phone:478-953-3535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1023370001Medicare NSC