Healthcare Provider Details

I. General information

NPI: 1770998254
Provider Name (Legal Business Name): CALEB MELLINGER PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 DANTIGNAC ST
AUGUSTA GA
30901-2774
US

IV. Provider business mailing address

2407 COMANCHE RD
AUGUSTA GA
30904-3405
US

V. Phone/Fax

Practice location:
  • Phone: 706-823-2807
  • Fax:
Mailing address:
  • Phone: 706-631-5202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001881
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT011582
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: