Healthcare Provider Details

I. General information

NPI: 1770078164
Provider Name (Legal Business Name): YDRECIOUS LABARON MILNER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 HOGAN RD SW
ATLANTA GA
30331-2830
US

IV. Provider business mailing address

3250 HOGAN RD SW
ATLANTA GA
30331-2830
US

V. Phone/Fax

Practice location:
  • Phone: 404-346-1526
  • Fax: 404-346-0729
Mailing address:
  • Phone: 404-346-1526
  • Fax: 404-346-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: