Basic Information
| Provider Information | |||||||||
| NPI: | 1083162978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENT PHYSICAL THERAPY OF GA, LLC | ||||||||
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| OtherOrganizationName: | BENCHMARK PT - POOLER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
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| Practice Location | |||||||||
| Address1: | 119 CANAL ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313224095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123308444 | ||||||||
| FaxNumber: | 9123308844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 4232383220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.