Provider Demographics
NPI:1851036057
Name:FOUNDATION PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:FOUNDATION PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:REGINALD
Authorized Official - Last Name:MACLWOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:678-446-8269
Mailing Address - Street 1:619 EDGEWOOD AVE SE STE T101
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1987
Mailing Address - Country:US
Mailing Address - Phone:404-565-4064
Mailing Address - Fax:678-550-9303
Practice Address - Street 1:619 EDGEWOOD AVE SE STE T101
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1987
Practice Address - Country:US
Practice Address - Phone:404-565-4064
Practice Address - Fax:678-550-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy