Basic Information
Provider Information | |||||||||
NPI: | 1699786012 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSIOTHERAPY ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHYSIOTHERAPY ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 1245 | ||||||||
Address2: |   | ||||||||
City: | INDIANA | ||||||||
State: | PA | ||||||||
PostalCode: | 157015245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7244653496 | ||||||||
FaxNumber: | 2154134682 | ||||||||
Practice Location | |||||||||
Address1: | 10090 MEDLOCK BRIDGE ROAD | ||||||||
Address2: | BLDG 400, SUITE 100 | ||||||||
City: | DULUTH | ||||||||
State: | GA | ||||||||
PostalCode: | 300974428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708135575 | ||||||||
FaxNumber: | 6153298274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 06/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POOL | ||||||||
AuthorizedOfficialFirstName: | JAYNE | ||||||||
AuthorizedOfficialMiddleName: | FLECK | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7244653496 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.