Healthcare Provider Details

I. General information

NPI: 1912675950
Provider Name (Legal Business Name): WILLIAM ALEXANDER HVIZDZAK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 09/03/2021
Certification Date: 09/01/2021
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

145 WOODARD RD
KATHLEEN GA
31047-2601
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-4563
  • Fax:
Mailing address:
  • Phone: 478-542-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015578
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: