Healthcare Provider Details

I. General information

NPI: 1366971277
Provider Name (Legal Business Name): PARK RIDGE HEALTHCARE AND PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2896 CHAMBLEE TUCKER ROAD SUITE 4
ATLANTA GA
30341
US

IV. Provider business mailing address

2896 CHAMBLEE TUCKER RD STE 2
ATLANTA GA
30341-4009
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-0584
  • Fax: 770-457-0773
Mailing address:
  • Phone: 770-457-0584
  • Fax: 770-457-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR002472
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICK JOSEPH SALLARULO
Title or Position: OWNER
Credential: DC
Phone: 770-457-0584