Provider Demographics
NPI:1578775771
Name:VALDOSTA PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:VALDOSTA PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JON
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:229-247-5225
Mailing Address - Street 1:2109 N PATTERSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2946
Mailing Address - Country:US
Mailing Address - Phone:229-247-5225
Mailing Address - Fax:229-241-8471
Practice Address - Street 1:2109 N PATTERSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2946
Practice Address - Country:US
Practice Address - Phone:229-247-5225
Practice Address - Fax:229-241-8471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 2251E1300X, 2251H1200X, 2251S0007X, 2251X0800X
GA2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3435Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER