Provider Demographics
NPI:1790947133
Name:PARKER, REGINALD A (PTA)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:A
Last Name:PARKER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MCFARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-2215
Mailing Address - Country:US
Mailing Address - Phone:706-861-0863
Mailing Address - Fax:706-861-3965
Practice Address - Street 1:1425 MCFARLAND AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-2215
Practice Address - Country:US
Practice Address - Phone:706-861-0863
Practice Address - Fax:706-861-3965
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA251314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility