Healthcare Provider Details

I. General information

NPI: 1235371295
Provider Name (Legal Business Name): FCE-PPD CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 RIVERSIDE DR SUITE C-5
MACON GA
31210-2521
US

IV. Provider business mailing address

3040 RIVERSIDE DR SUITE C-5
MACON GA
31210-2521
US

V. Phone/Fax

Practice location:
  • Phone: 478-475-9393
  • Fax: 478-475-9353
Mailing address:
  • Phone: 478-475-9393
  • Fax: 478-475-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT001629
License Number StateGA

VIII. Authorized Official

Name: LISA S BLANKENSHIP
Title or Position: DIRECTOR OF BUSINESS OPS
Credential: CWCP
Phone: 478-475-9393