Provider Demographics
NPI:1295847309
Name:SOUTHERN PHYSICAL & OCCUPATIONAL THERAPY SERVICES, INC
Entity type:Organization
Organization Name:SOUTHERN PHYSICAL & OCCUPATIONAL THERAPY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:229-423-8403
Mailing Address - Street 1:305 BENJAMIN H HILL DR W
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8720
Mailing Address - Country:US
Mailing Address - Phone:229-423-8403
Mailing Address - Fax:229-423-8340
Practice Address - Street 1:305 BENJAMIN H HILL DR W
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8720
Practice Address - Country:US
Practice Address - Phone:229-423-8403
Practice Address - Fax:229-423-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000451224Z00000X
GAPT004081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000785144BMedicaid
GA000785144BMedicaid
GA65BBDLLMedicare ID - Type Unspecified