Provider Demographics
NPI:1013956531
Name:COTTON RIDGE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:COTTON RIDGE PHYSICAL THERAPY LLC
Other - Org Name:ACCELERATED REHABILITATION CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-6560
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:219-365-6561
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:SUITE 100
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:912-681-7907
Practice Address - Fax:912-681-7860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 006923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4050Medicare PIN
CJ9548Medicare PIN