MEDICARE: WEST COBB PHYSICAL THERAPY

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	225100000X	Physical Therapist	PT007058	GA

General Provider Information

NPI Number	:	1417048885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COBB PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	5041 DALLAS HWY STE C
Second Line	:	BUILDING 1 SUITE C
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-6458
Country	:	US
Telephone Number	:	770-425-2151
Fax Number	:	770-425-5982

Provider Business Practice Location Address
First Line	:	5041 DALLAS HWY STE C
Second Line	:	BUILDING 1 SUITE C
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-6458
Country	:	US
Telephone Number	:	770-425-2151
Fax Number	:	770-425-5982

Authorized Official
Title or Position	:	DIRECTORE
Name	:	MR. RICHARD DARIN DURELL
Credential	:	PT
Telephone Number	:	770-425-2151

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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Practice Fax:

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