Healthcare Provider Details

I. General information

NPI: 1043870074
Provider Name (Legal Business Name): SPENCER BARON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 HIGHWAY 78 W STE 200
SNELLVILLE GA
30039-3929
US

IV. Provider business mailing address

1100 CIRCLE 75 PKWY SE
ATLANTA GA
30339-3064
US

V. Phone/Fax

Practice location:
  • Phone: 470-482-6933
  • Fax: 470-482-6940
Mailing address:
  • Phone: 678-403-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: