Healthcare Provider Details

I. General information

NPI: 1093395972
Provider Name (Legal Business Name): KYLE STAWITZKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 BOB ARNOLD BLVD STE A
LITHIA SPRINGS GA
30122-3258
US

IV. Provider business mailing address

939 BOB ARNOLD BLVD STE A
LITHIA SPRINGS GA
30122-3258
US

V. Phone/Fax

Practice location:
  • Phone: 770-769-1724
  • Fax:
Mailing address:
  • Phone: 770-769-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0102208053
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number113705
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: