Healthcare Provider Details

I. General information

NPI: 1649824012
Provider Name (Legal Business Name): GLENDORA L HURST DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 FLAT SHOALS RD SE
CONYERS GA
30094-6638
US

IV. Provider business mailing address

616 TREES OF AVALON PKWY
MCDONOUGH GA
30253-7602
US

V. Phone/Fax

Practice location:
  • Phone: 770-785-7669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number008353
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: