Provider Demographics
NPI:1740355304
Name:ATHLETIC SPINE REHABILITATION, LLC
Entity type:Organization
Organization Name:ATHLETIC SPINE REHABILITATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DSC, OCS
Authorized Official - Phone:770-792-7522
Mailing Address - Street 1:880 CANTON RD NE STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7283
Mailing Address - Country:US
Mailing Address - Phone:770-792-7522
Mailing Address - Fax:770-792-7508
Practice Address - Street 1:880 CANTON RD NE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7283
Practice Address - Country:US
Practice Address - Phone:770-792-7522
Practice Address - Fax:770-792-7508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4011Medicare ID - Type Unspecified