Basic Information
| Provider Information | |||||||||
| NPI: | 1679812127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS PERFORMANCE & REHABILITATION INSTITUTE LLC | ||||||||
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| OtherOrganizationName: | GEORGIA PHYSICAL THERAPY & SPORTS MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 VILLAGE PROFESSIONAL DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788809472 | ||||||||
| FaxNumber: | 6788809624 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 VILLAGE PROFESSIONAL DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788809472 | ||||||||
| FaxNumber: | 6788809624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2013 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | LUTH | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6788809472 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT006448 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.