Healthcare Provider Details

I. General information

NPI: 1639432669
Provider Name (Legal Business Name): LUANNE THOMAS KILGO OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 HIGHLAND AVE
SUMMERVILLE GA
30747-1930
US

IV. Provider business mailing address

46 KRISTY LN
RINGGOLD GA
30736-3054
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-4761
  • Fax:
Mailing address:
  • Phone: 706-965-4819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT002495
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: