Provider Demographics
NPI:1295909596
Name:NEUROSPORT PHYSICAL THERAPY@ELLARD LLC.
Entity type:Organization
Organization Name:NEUROSPORT PHYSICAL THERAPY@ELLARD LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MORIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-321-0155
Mailing Address - Street 1:8400 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE 480
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1837
Mailing Address - Country:US
Mailing Address - Phone:770-640-5470
Mailing Address - Fax:770-640-5471
Practice Address - Street 1:8400 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 480
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1837
Practice Address - Country:US
Practice Address - Phone:770-640-5470
Practice Address - Fax:770-640-5471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65PCBHTMedicare UPIN
GA65BBCZKMedicare UPIN