Provider Demographics
NPI:1619458163
Name:SMITH PHYSICAL THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:SMITH PHYSICAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:478-272-2100
Mailing Address - Street 1:1406 BELLEVUE RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2956
Mailing Address - Country:US
Mailing Address - Phone:478-272-2100
Mailing Address - Fax:478-272-2005
Practice Address - Street 1:1406 BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2956
Practice Address - Country:US
Practice Address - Phone:478-272-2100
Practice Address - Fax:478-272-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003195351AMedicaid