Provider Demographics
NPI:1528180692
Name:REHAB OF STONE MOUNTAIN
Entity Type:Organization
Organization Name:REHAB OF STONE MOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-850-0857
Mailing Address - Street 1:PO BOX 671821
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30006-1821
Mailing Address - Country:US
Mailing Address - Phone:770-469-1600
Mailing Address - Fax:770-469-2238
Practice Address - Street 1:6254 F MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083
Practice Address - Country:US
Practice Address - Phone:770-469-1600
Practice Address - Fax:770-469-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty