Provider Demographics
NPI:1942697362
Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Other - Org Name:BENCHMARK PT - BROOKHAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-8923
Mailing Address - Fax:
Practice Address - Street 1:705 TOWN BLVD NE STE 550
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-7216
Practice Address - Country:US
Practice Address - Phone:404-869-1912
Practice Address - Fax:404-869-6515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty