Provider Demographics
NPI:1558508580
Name:IDEAL THERAPY, LLC
Entity Type:Organization
Organization Name:IDEAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORLETTE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:LUKE-CAMBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:404-994-7727
Mailing Address - Street 1:290 HIGHWAY 314
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7813
Mailing Address - Country:US
Mailing Address - Phone:404-994-7727
Mailing Address - Fax:404-994-7728
Practice Address - Street 1:290 HIGHWAY 314
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7813
Practice Address - Country:US
Practice Address - Phone:404-994-7727
Practice Address - Fax:404-994-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty