Healthcare Provider Details

I. General information

NPI: 1912548959
Provider Name (Legal Business Name): IDEAL THERAPY REHABILITATIVE SERVICES II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6572 RIVER PARK DR STE 101
RIVERDALE GA
30274-2214
US

IV. Provider business mailing address

6572 RIVER PARK DR STE 101
RIVERDALE GA
30274-2214
US

V. Phone/Fax

Practice location:
  • Phone: 678-626-1833
  • Fax: 678-626-1844
Mailing address:
  • Phone: 678-626-1833
  • Fax: 678-626-1844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMSON SAINT-REMY
Title or Position: CEO
Credential:
Phone: 678-626-1833