Provider Demographics
NPI:1700965621
Name:DEVELOPMENTAL & REHABILITATIVE SERVICE, INC
Entity Type:Organization
Organization Name:DEVELOPMENTAL & REHABILITATIVE SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-879-5646
Mailing Address - Street 1:5295 STONE MOUNTAIN HWY
Mailing Address - Street 2:SUITE I
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6416
Mailing Address - Country:US
Mailing Address - Phone:770-879-5646
Mailing Address - Fax:770-981-2024
Practice Address - Street 1:5295 STONE MOUNTAIN HWY
Practice Address - Street 2:SUITE I
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6416
Practice Address - Country:US
Practice Address - Phone:770-879-5646
Practice Address - Fax:770-981-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007234PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309589OtherWELLCARE
GA000950595DMedicaid
GA10039295OtherAMERIGROUP
GA309589OtherWELLCARE