Basic Information
| Provider Information | |||||||||
| NPI: | 1013134824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE ATHLETIC THERAPY & REHAB INSTITUTE (ATARI) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 RIVERSIDE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312101395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784740240 | ||||||||
| FaxNumber: | 4784745043 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 RIVERSIDE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312101395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784740240 | ||||||||
| FaxNumber: | 4784745043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4784740240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT000866 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 007019 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.