Healthcare Provider Details

I. General information

NPI: 1629333968
Provider Name (Legal Business Name): KEVIN MICHAEL HURLEY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 WINN WAY SUITE 250
DECATUR GA
30030-1736
US

IV. Provider business mailing address

495 WINN WAY SUITE 250
DECATUR GA
30030-1736
US

V. Phone/Fax

Practice location:
  • Phone: 404-294-1313
  • Fax: 404-294-1318
Mailing address:
  • Phone: 404-294-1313
  • Fax: 404-294-1318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: