Provider Demographics
NPI:1679981781
Name:TOTALCARE WELLNESS AND PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:TOTALCARE WELLNESS AND PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BAYO
Authorized Official - Middle Name:UWAIFO
Authorized Official - Last Name:SEDENU
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PHD
Authorized Official - Phone:678-894-5628
Mailing Address - Street 1:1301 LOW WATER WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7079
Mailing Address - Country:US
Mailing Address - Phone:678-894-5628
Mailing Address - Fax:
Practice Address - Street 1:1301 LOW WATER WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7079
Practice Address - Country:US
Practice Address - Phone:678-894-5628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA14025628OtherCERTIFICATE OF ORGANIZATION