Provider Demographics
NPI:1477647816
Name:DOTHAN THERAPY ASSOCIATES INC
Entity Type:Organization
Organization Name:DOTHAN THERAPY ASSOCIATES INC
Other - Org Name:PHYSICAL THERAPY SPECIALISTS OF DOTHAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:334-673-2422
Mailing Address - Street 1:3118 ROSS CLARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-673-2422
Mailing Address - Fax:334-673-2425
Practice Address - Street 1:3118 ROSS CLARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-673-2422
Practice Address - Fax:334-673-2425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOTHAN THERAPY ASSOCIATES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ677OtherBC BS OF ALABAMA GROUP #
AL529912880Medicaid
ALDB4790Medicare PIN