Provider Demographics
NPI:1477987568
Name:BACK TO ACTION SPORTS REHAB, LLC.
Entity Type:Organization
Organization Name:BACK TO ACTION SPORTS REHAB, LLC.
Other - Org Name:GEORGIA SPORTS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAMAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:FRASIER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:410-688-3708
Mailing Address - Street 1:4936 GREEN POINTE WAY NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-1506
Mailing Address - Country:US
Mailing Address - Phone:410-688-3708
Mailing Address - Fax:
Practice Address - Street 1:754 PEACHTREE ST NE
Practice Address - Street 2:SUITE 105
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1206
Practice Address - Country:US
Practice Address - Phone:410-688-3708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty