Healthcare Provider Details

I. General information

NPI: 1861600520
Provider Name (Legal Business Name): GENESIS SPORTS MEDICINE AND REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 REDWINE RD SW
ATLANTA GA
30331-5582
US

IV. Provider business mailing address

3890 REDWINE RD SW SUITE 114
ATLANTA GA
30331-5582
US

V. Phone/Fax

Practice location:
  • Phone: 404-344-7880
  • Fax: 404-344-7881
Mailing address:
  • Phone: 404-344-7880
  • Fax: 404-344-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT006133
License Number StateGA

VIII. Authorized Official

Name: MR. KURT ANTHONY MCDONALD
Title or Position: PRESIDENT
Credential: PT , CSCS
Phone: 404-290-1700