Healthcare Provider Details

I. General information

NPI: 1093747503
Provider Name (Legal Business Name): LOLA SICARD ROSENBAUM DPT, PT, MHS, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 OSIGIAN BLVD THE CANTRELL CENTER FOR PHYSICAL THERAPY & SPORTS MEDIC
WARNER ROBINS GA
31088
US

IV. Provider business mailing address

405 OSIGIAN BLVD THE CANTRELL CENTER FOR PHYSICAL THERAPY & SPORTS MEDIC
WARNER ROBINS GA
31088
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-3535
  • Fax: 478-953-0353
Mailing address:
  • Phone: 478-953-3535
  • Fax: 478-953-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007078
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT007078
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: