Healthcare Provider Details

I. General information

NPI: 1093175465
Provider Name (Legal Business Name): MATTHEW LEVI HEROD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 MARTHA BERRY BLVD NW
ROME GA
30165-1623
US

IV. Provider business mailing address

1711 MARTHA BERRY BLVD NW
ROME GA
30165-1623
US

V. Phone/Fax

Practice location:
  • Phone: 706-528-4207
  • Fax: 706-528-4211
Mailing address:
  • Phone: 706-528-4207
  • Fax: 706-528-4211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA003589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: