Provider Demographics
NPI:1578610606
Name:BODY PROS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BODY PROS PHYSICAL THERAPY
Other - Org Name:AXIOM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:770-321-4720
Mailing Address - Street 1:1809 CANTON RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6343
Mailing Address - Country:US
Mailing Address - Phone:678-213-1560
Mailing Address - Fax:678-213-1705
Practice Address - Street 1:1809 CANTON RD
Practice Address - Street 2:SUITE 600
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6343
Practice Address - Country:US
Practice Address - Phone:678-213-1560
Practice Address - Fax:678-213-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108515261QP2000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7211Medicare PIN