Provider Demographics
NPI:1427218106
Name:AGAPE SPORTS PERFORMANCE WELLNESS AND REHAB
Entity Type:Organization
Organization Name:AGAPE SPORTS PERFORMANCE WELLNESS AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TOLA
Authorized Official - Middle Name:O C
Authorized Official - Last Name:AKOMOLAFE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT MS CCI CEAS
Authorized Official - Phone:770-839-0841
Mailing Address - Street 1:220 EAGLES LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8802
Mailing Address - Country:US
Mailing Address - Phone:404-839-0841
Mailing Address - Fax:
Practice Address - Street 1:402 BECKETT LANE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:404-839-0841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT 04336261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA166964592OtherNPPES/NPI