Healthcare Provider Details

I. General information

NPI: 1215167515
Provider Name (Legal Business Name): SOUTHERN REHAB AND SPORTS MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VERNON RD STE A
LAGRANGE GA
30240-3871
US

IV. Provider business mailing address

1805 VERNON RD SUITE A
LAGRANGE GA
30240-3871
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-9383
  • Fax: 706-845-9482
Mailing address:
  • Phone: 706-845-9383
  • Fax: 706-845-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8954
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. JOSHUA D MCGINTY
Title or Position: VICE PRESIDENT, PHYSICAL THERAPIST
Credential: DPT, ATC
Phone: 706-845-9383