Healthcare Provider Details

I. General information

NPI: 1003868225
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY OF GEORGIA , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date: 12/21/2006
Reactivation Date: 05/27/2008

III. Provider practice location address

785 SHUGART RD STE 10
DALTON GA
30720-2478
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-0816
  • Fax: 706-226-9584
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
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRYAN BARGANIER
Title or Position: CFO
Credential:
Phone: 205-536-7602