MEDICARE: MILTON PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1043742281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILTON PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	1410 WOOD DUCK RD
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-4636
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12220 BIRMINGHAM HWY
Second Line	:	BLDG10 / STE C
City	:	MILTON
State	:	GA
Zip	:	30004-4186
Country	:	US
Telephone Number	:	770-826-0440
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIM CHASTAIN
Credential	:	DPT
Telephone Number	:	770-826-0440

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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