Basic Information
| Provider Information | |||||||||
| NPI: | 1801272273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 BRASELTON HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300194666 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3605 BRASELTON HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300194666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709040772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | NEWSOME | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3367827461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 012019 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.