Provider Demographics
NPI:1437481637
Name:CUSTOMIZED PHYSICAL THERAPY SERVICES INC
Entity Type:Organization
Organization Name:CUSTOMIZED PHYSICAL THERAPY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDE REGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-485-2109
Mailing Address - Street 1:1398 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2661
Mailing Address - Country:US
Mailing Address - Phone:770-485-2109
Mailing Address - Fax:770-485-2109
Practice Address - Street 1:1398 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2661
Practice Address - Country:US
Practice Address - Phone:770-485-2109
Practice Address - Fax:770-485-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty