Healthcare Provider Details

I. General information

NPI: 1992568539
Provider Name (Legal Business Name): BROOKS EDWARD PENDLETON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 WHEELER RD
AUGUSTA GA
30909-6426
US

IV. Provider business mailing address

1426 TWIGGS ST
AUGUSTA GA
30901-3612
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-3232
  • Fax:
Mailing address:
  • Phone: 770-296-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: