Basic Information
| Provider Information | |||||||||
| NPI: | 1104112408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORRELL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | D.P.T | ||||||||
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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: | 3540 COBB PKWY NW | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301014178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785016300 | ||||||||
| FaxNumber: | 6783843318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT010253 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.