Provider Demographics
NPI:1497858781
Name:CENTER FOR PHYSICAL REHABILITATION, INC.
Entity Type:Organization
Organization Name:CENTER FOR PHYSICAL REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REVAJO
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROADWATER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:229-333-0095
Mailing Address - Street 1:3537 NORTH CROSSING CIRCLE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-333-0095
Mailing Address - Fax:229-333-0756
Practice Address - Street 1:3537 N CROSSING CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-333-0095
Practice Address - Fax:229-333-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116767Medicare Oscar/Certification