Provider Demographics
NPI:1457840290
Name:FORM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FORM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:678-936-0821
Mailing Address - Street 1:4005 DOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3283
Mailing Address - Country:US
Mailing Address - Phone:678-936-0821
Mailing Address - Fax:
Practice Address - Street 1:1295 HEMBREE RD STE A201
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:678-936-0821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty