Provider Demographics
NPI:1912188962
Name:GEORGIA SPORTS THERAPY AND REHABILITATION
Entity Type:Organization
Organization Name:GEORGIA SPORTS THERAPY AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MALLARE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:770-932-3212
Mailing Address - Street 1:3511 BRASELTON HWY
Mailing Address - Street 2:STE G-2
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5925
Mailing Address - Country:US
Mailing Address - Phone:770-932-3212
Mailing Address - Fax:770-932-3577
Practice Address - Street 1:3511 BRASELTON HWY
Practice Address - Street 2:STE G-2
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5925
Practice Address - Country:US
Practice Address - Phone:770-932-3212
Practice Address - Fax:770-932-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP86186Medicare UPIN
GA65BBDMKMedicare PIN