Healthcare Provider Details

I. General information

NPI: 1801292982
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 S PARK ST STE B
CARROLLTON GA
30117-4456
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-8702
  • Fax: 770-830-8106
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LISA BENETTO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 423-238-8923