Healthcare Provider Details

I. General information

NPI: 1780595553
Provider Name (Legal Business Name): KAVON DOMINICK FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 CUMBERLAND PKWY SE
ATLANTA GA
30339-1808
US

IV. Provider business mailing address

4381 PIPEMAKER BLF
DOUGLASVILLE GA
30135-8219
US

V. Phone/Fax

Practice location:
  • Phone: 770-670-4184
  • Fax:
Mailing address:
  • Phone: 404-423-9929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017637
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: