Healthcare Provider Details

I. General information

NPI: 1760751077
Provider Name (Legal Business Name): BODY MECHANICS REHABILITATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 NEW RIVER WAY
MCDONOUGH GA
30252-4153
US

IV. Provider business mailing address

524 NEW RIVER WAY
MCDONOUGH GA
30252-4153
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-3422
  • Fax: 678-444-4559
Mailing address:
  • Phone: 678-817-3422
  • Fax: 678-444-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberOT002225
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberOT002225
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberOT002225
License Number StateGA

VIII. Authorized Official

Name: MRS. LETORSHA HOM
Title or Position: ACCOUNT EXECUTIVE
Credential:
Phone: 678-817-3422