Basic Information
| Provider Information | |||||||||
| NPI: | 1255060307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOMETOWN ORTHOPEDIC AND SPORTS REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 STONE EDGE DR | ||||||||
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| City: | GRAY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310325546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4785503702 | ||||||||
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| Practice Location | |||||||||
| Address1: | 260 W CLINTON ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310325464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4785503702 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4785503702 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 06/06/2022 | ||||||||
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.