Provider Demographics
NPI:1770530644
Name:TRI-COUNTY REHABILITATION & PAIN, LLC
Entity type:Organization
Organization Name:TRI-COUNTY REHABILITATION & PAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-858-6056
Mailing Address - Street 1:102 GROSS CRESCENT CIR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 GROSS CRESCENT CIR
Practice Address - Street 2:SUITE 203
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3600
Practice Address - Country:US
Practice Address - Phone:706-858-6056
Practice Address - Fax:706-858-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4518Medicare PIN
TN3381162Medicare PIN