Provider Demographics
NPI:1558782474
Name:PEMBERTON & ASSOCIATES
Entity Type:Organization
Organization Name:PEMBERTON & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT/OTR
Authorized Official - Phone:770-725-9271
Mailing Address - Street 1:2253 ALLEGHENY LN
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-8347
Mailing Address - Country:US
Mailing Address - Phone:770-725-9271
Mailing Address - Fax:770-725-2985
Practice Address - Street 1:2253 ALLEGHENY LN
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-8347
Practice Address - Country:US
Practice Address - Phone:770-725-9271
Practice Address - Fax:770-725-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002327225100000X
GAOT000620225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1093938722OtherNPI