Basic Information
| Provider Information | |||||||||
| NPI: | 1114054343 | ||||||||
| 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: | 3343962110 | ||||||||
| FaxNumber: | 3343962115 | ||||||||
| Practice Location | |||||||||
| Address1: | 1899 LAKE RD | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | HIRAM | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301412291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709431142 | ||||||||
| FaxNumber: | 7709170926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | YAKE | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3343962110 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PT SOLUTIONS OF ACWORTH LLC | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.