Healthcare Provider Details

I. General information

NPI: 1699612846
Provider Name (Legal Business Name): OUTLAST SPORTS REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 RONNELL RD BLDG 300
HOLLY SPRINGS GA
30115-8636
US

IV. Provider business mailing address

330 RONNELL RD BLDG 300
HOLLY SPRINGS GA
30115-8636
US

V. Phone/Fax

Practice location:
  • Phone: 404-308-0817
  • Fax:
Mailing address:
  • Phone: 404-308-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADLEY EARNEST
Title or Position: OWNER
Credential: PT, DPT, CSCS
Phone: 404-308-0817