Basic Information
| Provider Information | |||||||||
| NPI: | 1538540893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEGIS GROUP PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FIANNA WAY | ||||||||
| Address2: | MAIL DROP 4840 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729194840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792014840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 895 CANTON RD NE | ||||||||
| Address2: | BLDG 200, STE 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300608934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778238375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEGIS THERAPIES, INC. | ||||||||
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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 | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.