Basic Information
| Provider Information | |||||||||
| NPI: | 1083895973 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PT SOLUTIONS OF ACWORTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242278 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361242278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343963273 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 9390 THE LANDING DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708521692 | ||||||||
| FaxNumber: | 7708521694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 02/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | YAKE | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7708521692 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PT SOLUTIONS OF ACWORTH LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.