Healthcare Provider Details

I. General information

NPI: 1992745764
Provider Name (Legal Business Name): GWINNETT PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WATER SHINE WAY
SNELLVILLE GA
30078-7380
US

IV. Provider business mailing address

1305 WATER SHINE WAY
SNELLVILLE GA
30078-7380
US

V. Phone/Fax

Practice location:
  • Phone: 770-972-8536
  • Fax:
Mailing address:
  • Phone: 770-972-8536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003089
License Number StateGA

VIII. Authorized Official

Name: MRS. ROOPA M DESAI
Title or Position: DIRECTOR
Credential: PT
Phone: 770-972-8536