Healthcare Provider Details

I. General information

NPI: 1124245295
Provider Name (Legal Business Name): DEKALBPHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5462 MEMORIAL DR SUITE 203
STONE MTN GA
30083-3239
US

IV. Provider business mailing address

5462 MEMORIAL DR SUITE 203
STONE MTN GA
30083-3239
US

V. Phone/Fax

Practice location:
  • Phone: 770-491-1353
  • Fax: 770-723-9653
Mailing address:
  • Phone: 770-491-1353
  • Fax: 404-297-9329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number295
License Number StateGA

VIII. Authorized Official

Name: MR. ROBERT L. MCNEIL
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 404-297-9330