Healthcare Provider Details

I. General information

NPI: 1477078699
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 KIA DR STE B
LAGRANGE GA
30241-3731
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 706-668-6336
  • Fax: 706-668-6033
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JOHANNESON
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 423-238-3220