Provider Demographics
NPI:1972659332
Name:PT SOLUTIONS OF ACWORTH, LLC
Entity Type:Organization
Organization Name:PT SOLUTIONS OF ACWORTH, LLC
Other - Org Name:WOODSTOCK PHYSICAL THERAPY AND PERFORMANCE INSTITUTE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:678-403-3560
Mailing Address - Street 1:PO BOX 242278
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2278
Mailing Address - Country:US
Mailing Address - Phone:334-625-5795
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:1816 EAGLE DR
Practice Address - Street 2:BUILDING 100, SUITE C
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8272
Practice Address - Country:US
Practice Address - Phone:770-516-9191
Practice Address - Fax:678-802-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6455Medicare PIN