Basic Information
| Provider Information | |||||||||
| NPI: | 1477909364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TATTNALL HOSPITAL COMPANY LLC | ||||||||
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| OtherOrganizationName: | OPTIM THERAPY - VIDALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 MALL BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126441626 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 E 1ST ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125370888 | ||||||||
| FaxNumber: | 9125378820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2016 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9126445346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.