MEDICARE: INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1548796816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 LONG BRANCH RD
Second Line	:	UNIT 103
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-7132
Country	:	US
Telephone Number	:	706-864-0200
Fax Number	:	706-864-0072

Authorized Official
Title or Position	:	VP REVENUE CYCLE
Name	:	KEVIN JOHANNESON
Credential	:
Telephone Number	:	423-238-3220

Provider Enumeration Date	:	05/05/2017
Last Update Date	:	05/05/2017

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