Provider Demographics
NPI:1912548959
Name:IDEAL THERAPY REHABILITATIVE SERVICES II, LLC
Entity Type:Organization
Organization Name:IDEAL THERAPY REHABILITATIVE SERVICES II, LLC
Other - Org Name:IDEAL THERAPY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORLETTE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:LUKE-CAMBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-994-7727
Mailing Address - Street 1:6572 RIVER PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2214
Mailing Address - Country:US
Mailing Address - Phone:678-626-1833
Mailing Address - Fax:678-626-1844
Practice Address - Street 1:6572 RIVER PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2214
Practice Address - Country:US
Practice Address - Phone:678-626-1833
Practice Address - Fax:678-626-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation