Healthcare Provider Details

I. General information

NPI: 1598840282
Provider Name (Legal Business Name): CERTIFIED REHAB OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S GREENWOOD ST
LAGRANGE GA
30240-3122
US

IV. Provider business mailing address

302 S GREENWOOD ST
LAGRANGE GA
30240-3122
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-8360
  • Fax: 706-884-0265
Mailing address:
  • Phone: 706-884-8360
  • Fax: 706-884-0265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLIC006138
License Number StateGA

VIII. Authorized Official

Name: JAMES R ASPINWALL
Title or Position: PRESIDENT
Credential:
Phone: 706-884-8360