Basic Information
| Provider Information | |||||||||
| NPI: | 1972659332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PT SOLUTIONS OF ACWORTH, LLC | ||||||||
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| OtherOrganizationName: | WOODSTOCK PHYSICAL THERAPY AND PERFORMANCE INSTITUTE, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242278 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361242278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346255795 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 1816 EAGLE DR | ||||||||
| Address2: | BUILDING 100, SUITE C | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301898272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705169191 | ||||||||
| FaxNumber: | 6788027377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | YAKE | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6784033560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.