Provider Demographics
NPI:1679915284
Name:MILESTONE PEDIATRIC THERAPY SERVICES INC.
Entity Type:Organization
Organization Name:MILESTONE PEDIATRIC THERAPY SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:MSOTR/L
Authorized Official - Phone:678-863-2074
Mailing Address - Street 1:526 JEFFERSON WALK CIR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-5573
Mailing Address - Country:US
Mailing Address - Phone:678-863-2074
Mailing Address - Fax:706-367-2431
Practice Address - Street 1:526 JEFFERSON WALK CIR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-5573
Practice Address - Country:US
Practice Address - Phone:678-863-2074
Practice Address - Fax:706-367-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004043261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA372085900HMedicaid