Basic Information
Provider Information | |||||||||
NPI: | 1295099802 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRIDGES | ||||||||
FirstName: | KACI | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, CHT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MYERS | ||||||||
OtherFirstName: | KACI | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 15 MEDICAL DR NE STE 101 | ||||||||
Address2: |   | ||||||||
City: | CARTERSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301218005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703865221 | ||||||||
FaxNumber: | 7703861128 | ||||||||
Practice Location | |||||||||
Address1: | 15 MEDICAL DR NE STE 101 | ||||||||
Address2: |   | ||||||||
City: | CARTERSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 30121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703865221 | ||||||||
FaxNumber: | 7703861128 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2012 | ||||||||
LastUpdateDate: | 06/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251H1200X | 5186 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
No ID Information.