Healthcare Provider Details

I. General information

NPI: 1295117273
Provider Name (Legal Business Name): BCD REHAB & FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 FRANCES MEEKS WAY STE 5
RICHMOND HILL GA
31324-3984
US

IV. Provider business mailing address

128 FRANCES MEEKS WAY STE 5
RICHMOND HILL GA
31324-3984
US

V. Phone/Fax

Practice location:
  • Phone: 912-727-2321
  • Fax:
Mailing address:
  • Phone: 912-727-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number15058193
License Number StateGA

VIII. Authorized Official

Name: DR. JACLYN MEADOWS DELOACH
Title or Position: PHYSICAL THERAPIST, OWNER
Credential: PT, DPT, MS
Phone: 912-727-2321