Basic Information
| Provider Information | |||||||||
| NPI: | 1326403361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300402434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708892163 | ||||||||
| FaxNumber: | 7708894385 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300402434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708892163 | ||||||||
| FaxNumber: | 7708894385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2015 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | LAURRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | AREA VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6784597792 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT,DPT,MHS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT012173 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.