Provider Demographics
NPI:1619281961
Name:PROVENANCE REHABILITATION
Entity Type:Organization
Organization Name:PROVENANCE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BUSBEE
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-570-9500
Mailing Address - Street 1:310 AURELIA TRCE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4358
Mailing Address - Country:US
Mailing Address - Phone:678-570-9500
Mailing Address - Fax:
Practice Address - Street 1:11975 MORRIS RD
Practice Address - Street 2:SUITE 310
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4419
Practice Address - Country:US
Practice Address - Phone:678-819-8720
Practice Address - Fax:678-819-8721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20111729283261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy