Provider Demographics
NPI:1962669275
Name:BACK IN THE GAME PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:BACK IN THE GAME PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-570-2584
Mailing Address - Street 1:4754 MARTIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3507
Mailing Address - Country:US
Mailing Address - Phone:770-967-4377
Mailing Address - Fax:770-967-8077
Practice Address - Street 1:4754 MARTIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3507
Practice Address - Country:US
Practice Address - Phone:770-967-4377
Practice Address - Fax:770-967-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy