Healthcare Provider Details

I. General information

NPI: 1164249033
Provider Name (Legal Business Name): BEAU NIKOLAS PEREGINO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2743
  • Fax:
Mailing address:
  • Phone: 706-721-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: