Provider Demographics
NPI:1659513588
Name:VANCE, TIMOTHY ALLEN (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:VANCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-802-1991
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:201 TURNER MCCALL BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2545
Practice Address - Country:US
Practice Address - Phone:706-235-2727
Practice Address - Fax:706-235-2726
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA460976432A,B,C,D,E,FMedicaid