Provider Demographics
NPI:1255990123
Name:CLUB PT, LLC
Entity type:Organization
Organization Name:CLUB PT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS,FAAOMPT
Authorized Official - Phone:706-255-1150
Mailing Address - Street 1:2347 BROOKHURST DR
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6631
Mailing Address - Country:US
Mailing Address - Phone:706-255-1150
Mailing Address - Fax:
Practice Address - Street 1:53 W BROOKHAVEN DR NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-1101
Practice Address - Country:US
Practice Address - Phone:706-255-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy