Healthcare Provider Details

I. General information

NPI: 1518999028
Provider Name (Legal Business Name): PHYSICAL THERAPY PLUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W VILLANOW ST
LA FAYETTE GA
30728-2463
US

IV. Provider business mailing address

120 W VILLANOW ST
LA FAYETTE GA
30728-2463
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5983
  • Fax: 706-638-3612
Mailing address:
  • Phone: 706-638-5983
  • Fax: 706-638-3612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number006870
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005339
License Number StateGA

VIII. Authorized Official

Name: LATEFA TERRY
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: P.T.
Phone: 423-490-1295