Provider Demographics
NPI:1437545324
Name:NEUROSPORT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:NEUROSPORT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-321-0155
Mailing Address - Street 1:1163 JOHNSON FERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2764
Mailing Address - Country:US
Mailing Address - Phone:770-321-0155
Mailing Address - Fax:
Practice Address - Street 1:1163 JOHNSON FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2764
Practice Address - Country:US
Practice Address - Phone:770-321-0155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65PCBHTMedicare PIN