Provider Demographics
NPI:1922379189
Name:1SOURCE FITNESS & SPORTS-NEURO REHAB LLC
Entity Type:Organization
Organization Name:1SOURCE FITNESS & SPORTS-NEURO REHAB LLC
Other - Org Name:ONESOURCE SPORTS NEURO REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR. OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADU
Authorized Official - Suffix:
Authorized Official - Credentials:DPTMBAFAAOMPT
Authorized Official - Phone:678-257-4037
Mailing Address - Street 1:1670 MCKENDREE CHURCH RD STE 40
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4100
Mailing Address - Country:US
Mailing Address - Phone:678-257-4037
Mailing Address - Fax:678-819-7536
Practice Address - Street 1:1670 MCKENDREE CHURCH RD STE 40
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4100
Practice Address - Country:US
Practice Address - Phone:678-257-4037
Practice Address - Fax:678-819-7536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009750261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00319995AMedicaid