MEDICARE: VALDOSTA PHYSICAL THERAPY, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	2251E1300X	Clinical Electrophysiology Physical Therapist
2	2251H1200X	Hand Physical Therapist
3	2251S0007X	Sports Physical Therapist
4	2251X0800X	Orthopedic Physical Therapist
5	2251S0007X	Sports Physical Therapist	GA
6	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1578775771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALDOSTA PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	2109 N PATTERSON ST
Second Line	:	SUITE A
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2946
Country	:	US
Telephone Number	:	229-247-5225
Fax Number	:	229-241-8471

Provider Business Practice Location Address
First Line	:	2109 N PATTERSON ST
Second Line	:	SUITE A
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2946
Country	:	US
Telephone Number	:	229-247-5225
Fax Number	:	229-241-8471

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RAYMOND JON KING
Credential	:	MBA
Telephone Number	:	229-247-5225

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	09/27/2007

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