Provider Demographics
NPI:1184239972
Name:TIDWELL, LUKE EIDSON (PT)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:EIDSON
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 HIGHWAY 34 E STE 1300
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3186
Mailing Address - Country:US
Mailing Address - Phone:770-254-7850
Mailing Address - Fax:
Practice Address - Street 1:1755 HIGHWAY 34 E STE 1300
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3186
Practice Address - Country:US
Practice Address - Phone:770-254-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist