Healthcare Provider Details

I. General information

NPI: 1962743674
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11172 HIGHWAY 142 N
COVINGTON GA
30014-2547
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 678-712-3692
  • Fax: 678-712-3693
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JOHANNESON
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 423-238-2313