Healthcare Provider Details

I. General information

NPI: 1982887543
Provider Name (Legal Business Name): PRO HEALTH AND REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 POWDER SPRINGS RD SW SUITE 215
MARIETTA GA
30064-4570
US

IV. Provider business mailing address

2453 POWDER SPRINGS RD SW SUITE 215
MARIETTA GA
30064-4570
US

V. Phone/Fax

Practice location:
  • Phone: 678-567-2313
  • Fax: 855-771-9101
Mailing address:
  • Phone: 678-567-2313
  • Fax: 855-771-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR006384
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39009
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number68404
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN191854
License Number StateGA

VIII. Authorized Official

Name: STEFAN CHARLES G SABOURA
Title or Position: OWNER/ PROVIDER
Credential: DC
Phone: 678-567-2313