Provider Demographics
NPI:1245826999
Name:GEORGIA LUNA CARE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:GEORGIA LUNA CARE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-867-0522
Mailing Address - Street 1:PO BOX 2350
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-8350
Mailing Address - Country:US
Mailing Address - Phone:650-867-0522
Mailing Address - Fax:
Practice Address - Street 1:504 EVERETT ST
Practice Address - Street 2:
Practice Address - City:ST SIMONS IS
Practice Address - State:GA
Practice Address - Zip Code:31522-4605
Practice Address - Country:US
Practice Address - Phone:877-839-6979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty