Healthcare Provider Details

I. General information

NPI: 1306365895
Provider Name (Legal Business Name): LARRY DAVID YOUNGBLOOD III PT, DPT, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 WATSON BLVD STE 525
WARNER ROBINS GA
31093-8556
US

IV. Provider business mailing address

3051 WATSON BLVD STE 525
WARNER ROBINS GA
31093-8556
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-4563
  • Fax: 478-953-4563
Mailing address:
  • Phone: 478-953-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016469
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003284
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: