MEDICARE: BACK IN THE GAME 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	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1962669275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK IN THE GAME PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	4754 MARTIN RD
Second Line	:	SUITE 200
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-3507
Country	:	US
Telephone Number	:	770-967-4377
Fax Number	:	770-967-8077

Provider Business Practice Location Address
First Line	:	4754 MARTIN RD
Second Line	:	SUITE 200
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-3507
Country	:	US
Telephone Number	:	770-967-4377
Fax Number	:	770-967-8077

Authorized Official
Title or Position	:	CO-OWNER
Name	:	GINA RENEE BLAKE
Credential	:	PT
Telephone Number	:	678-570-2584

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	11/15/2011

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