Healthcare Provider Details

I. General information

NPI: 1508522418
Provider Name (Legal Business Name): ELEVATE PHYSICAL THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7745 PARKSIDE DR
LITHIA SPRINGS GA
30122-6871
US

IV. Provider business mailing address

7745 PARKSIDE DR
LITHIA SPRINGS GA
30122-6871
US

V. Phone/Fax

Practice location:
  • Phone: 321-276-2353
  • Fax:
Mailing address:
  • Phone: 321-276-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JESSICA MASHAUN BIVINS
Title or Position: OWNER/PT
Credential:
Phone: 321-276-2353