Healthcare Provider Details

I. General information

NPI: 1578610606
Provider Name (Legal Business Name): BODY PROS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 01/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 CANTON RD SUITE 600
MARIETTA GA
30066-6343
US

IV. Provider business mailing address

1809 CANTON RD SUITE 600
MARIETTA GA
30066-6343
US

V. Phone/Fax

Practice location:
  • Phone: 678-213-1560
  • Fax: 678-213-1705
Mailing address:
  • Phone: 678-213-1560
  • Fax: 678-213-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number108515
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number108515
License Number StateGA

VIII. Authorized Official

Name: MR. JOHN A. RESNICK
Title or Position: DIRECTOR OF OPERATIONS
Credential: J.D.
Phone: 770-321-4720