Provider Demographics
NPI:1679264659
Name:LEGACY ORTHOPEDIC REHAB LLC
Entity Type:Organization
Organization Name:LEGACY ORTHOPEDIC REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-886-7400
Mailing Address - Street 1:165 HICKORY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6343
Mailing Address - Country:US
Mailing Address - Phone:229-886-7400
Mailing Address - Fax:
Practice Address - Street 1:2462 HIGHWAY 34 E STE E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2378
Practice Address - Country:US
Practice Address - Phone:229-886-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty