Provider Demographics
NPI:1699858191
Name:WELLSPRING THERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:WELLSPRING THERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRAYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:706-348-2004
Mailing Address - Street 1:10 S. BROOK ST.
Mailing Address - Street 2:STE. 2
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-0014
Mailing Address - Country:US
Mailing Address - Phone:706-348-2004
Mailing Address - Fax:706-348-2014
Practice Address - Street 1:10 S BROOK ST
Practice Address - Street 2:SUITE 2
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1151
Practice Address - Country:US
Practice Address - Phone:706-348-2004
Practice Address - Fax:706-348-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0400X
GA624036001332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116864Medicare ID - Type UnspecifiedREHAB AGENCY
GA6240360001Medicare NSC