Provider Demographics
NPI:1669734554
Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Entity type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:4959 BILL GARDNER PKWY
Mailing Address - Street 2:STE 109
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2915
Mailing Address - Country:US
Mailing Address - Phone:770-914-9285
Mailing Address - Fax:770-914-5668
Practice Address - Street 1:8823 PRODUCTION LN
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-6511
Practice Address - Country:US
Practice Address - Phone:423-238-7217
Practice Address - Fax:423-238-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine