Provider Demographics
NPI:1760848345
Name:GEORGIA PELVIC PT, LLC
Entity Type:Organization
Organization Name:GEORGIA PELVIC PT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/SOLE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LARA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:706-767-4419
Mailing Address - Street 1:108 ROBIN ST NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 ROBIN ST NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1544
Practice Address - Country:US
Practice Address - Phone:706-767-4419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty