Healthcare Provider Details

I. General information

NPI: 1144741976
Provider Name (Legal Business Name): PROVISION PHYSICAL THERAPY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

105 COMMERCE DR STE B
FAYETTEVILLE GA
30214-7352
US

IV. Provider business mailing address

105 COMMERCE DR STE B
FAYETTEVILLE GA
30214-7352
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-1654
  • Fax:
Mailing address:
  • Phone: 404-692-1654
  • Fax: 404-393-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT009550
License Number StateGA

VIII. Authorized Official

Name: VENILLA BARNES
Title or Position: PHYSICAL THERAPIST
Credential: PT,DPT
Phone: 404-692-1654