Healthcare Provider Details

I. General information

NPI: 1740355304
Provider Name (Legal Business Name): ATHLETIC SPINE REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 CANTON RD NE STE 100
MARIETTA GA
30060-7283
US

IV. Provider business mailing address

880 CANTON RD NE STE 100
MARIETTA GA
30060-7283
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-7522
  • Fax: 770-792-7508
Mailing address:
  • Phone: 770-792-7522
  • Fax: 770-792-7508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. HERBERT L SILVER
Title or Position: OWNER
Credential: PT, DSC, OCS
Phone: 770-792-7522