Provider Demographics
NPI:1942788310
Name:BIRDS OF PARADISE HOME WELLNESS AND PHYSICAL THERAPY SERVICES,LLC
Entity Type:Organization
Organization Name:BIRDS OF PARADISE HOME WELLNESS AND PHYSICAL THERAPY SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PTA
Authorized Official - Prefix:
Authorized Official - First Name:JAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-651-4902
Mailing Address - Street 1:754 POST ROAD LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 S HAIRSTON RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-3535
Practice Address - Country:US
Practice Address - Phone:678-651-4902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-29
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003477225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty