Healthcare Provider Details

I. General information

NPI: 1497781942
Provider Name (Legal Business Name): PEACHTREE ORTHOPAEDIC CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 PHOENIX BLVD SUITE 120
COLLEGE PARK GA
30349-5588
US

IV. Provider business mailing address

1901 PHOENIX BLVD SUITE 120
COLLEGE PARK GA
30349-5588
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-6548
  • Fax: 770-996-7299
Mailing address:
  • Phone: 404-355-6548
  • Fax: 770-996-7299

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: GREG COOPER
Title or Position: MANAGING PARTNER
Credential:
Phone: 219-365-6560