Healthcare Provider Details

I. General information

NPI: 1376259077
Provider Name (Legal Business Name): THERA-CORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 04/20/2023
Certification Date: 04/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 WELLESLEY PL
RIVERDALE GA
30296-2972
US

IV. Provider business mailing address

1313 WELLESLEY PL
RIVERDALE GA
30296-2972
US

V. Phone/Fax

Practice location:
  • Phone: 404-457-3256
  • Fax:
Mailing address:
  • Phone: 404-457-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARRYL S PIPKIN
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 404-457-3256