Basic Information
| Provider Information | |||||||||
| NPI: | 1508309667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 441146 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301609522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784593745 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7057 HALCYON SUMMIT DR | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361176927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346255809 | ||||||||
| FaxNumber: | 3342712555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH8247 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.