Healthcare Provider Details

I. General information

NPI: 1972941839
Provider Name (Legal Business Name): BEYOND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1376 LAMONT DR SW
MABLETON GA
30126-1182
US

IV. Provider business mailing address

PO BOX 1787
MABLETON GA
30126-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-483-7081
  • Fax:
Mailing address:
  • Phone: 404-483-7081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SPENCER WINGATE
Title or Position: OWNER
Credential: P.T, D.P.T
Phone: 404-483-7081