Provider Demographics
NPI:1477858421
Name:CORVIC GROUP
Entity Type:Organization
Organization Name:CORVIC GROUP
Other - Org Name:PHYSIO LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-919-6835
Mailing Address - Street 1:102 WOODEN EAGLE TRL
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-4137
Mailing Address - Country:US
Mailing Address - Phone:478-919-6835
Mailing Address - Fax:
Practice Address - Street 1:107 PEACOCK DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3637
Practice Address - Country:US
Practice Address - Phone:478-919-6835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy