Provider Demographics
NPI:1861671935
Name:ANDRADA PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:ANDRADA PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:BANADOS
Authorized Official - Last Name:ANDRADA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:478-405-7010
Mailing Address - Street 1:3356 VINEVILLE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2328
Mailing Address - Country:US
Mailing Address - Phone:478-405-7010
Mailing Address - Fax:478-405-7012
Practice Address - Street 1:3356 VINEVILLE AVE
Practice Address - Street 2:STE C
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2328
Practice Address - Country:US
Practice Address - Phone:478-405-7010
Practice Address - Fax:478-405-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4707261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)