Basic Information
| Provider Information | |||||||||
| NPI: | 1962868620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONE ON ONE PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 NORTHEAST EXPY NE | ||||||||
| Address2: | BLDG 8, SUITE #C | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303413932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705003848 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 NORTHEAST EXPY NE | ||||||||
| Address2: | BLDG 8, SUITE #C | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303413932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705003848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | BLAIR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / VP | ||||||||
| AuthorizedOfficialTelephone: | 7705003848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 00174908 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 202G701013 | 01 | GA | PTAN | OTHER |