Provider Demographics
NPI:1184174161
Name:1SOURCE FITNESS & SPORTS NEURO REHAB
Entity type:Organization
Organization Name:1SOURCE FITNESS & SPORTS NEURO REHAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADU
Authorized Official - Suffix:
Authorized Official - Credentials:DPTGCS MBA
Authorized Official - Phone:678-250-4035
Mailing Address - Street 1:4728 JOSEPH ELI DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-7138
Mailing Address - Country:US
Mailing Address - Phone:678-257-4037
Mailing Address - Fax:678-257-4037
Practice Address - Street 1:4728 JOSEPH ELI DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-7138
Practice Address - Country:US
Practice Address - Phone:678-257-4037
Practice Address - Fax:678-257-4037
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1SOURCE FITNESS & SPORTS NEURO REHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12002969251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health