Provider Demographics
NPI:1467676924
Name:ATLANTA BACK CLINIC - ORTHOPEDIC PHYS THERAPY & TRAINING CTR INC
Entity Type:Organization
Organization Name:ATLANTA BACK CLINIC - ORTHOPEDIC PHYS THERAPY & TRAINING CTR INC
Other - Org Name:ATLANTA BACK CLINIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:404-274-5169
Mailing Address - Street 1:1901 MONTREAL RD STE 117
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5246
Mailing Address - Country:US
Mailing Address - Phone:770-491-6004
Mailing Address - Fax:770-723-0872
Practice Address - Street 1:1901 MONTREAL RD STE 117
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5246
Practice Address - Country:US
Practice Address - Phone:770-491-6004
Practice Address - Fax:770-723-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000897225100000X
GA005459225100000X
GA008394225100000X
GA007858225100000X
GA005876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP30Medicare UPIN