Healthcare Provider Details

I. General information

NPI: 1265789143
Provider Name (Legal Business Name): KEVIN WILLENBRING PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MOORES GROVE RD
WINTERVILLE GA
30683-1517
US

IV. Provider business mailing address

500 MARKET ST SUITE 103
BEAVER PA
15009-2998
US

V. Phone/Fax

Practice location:
  • Phone: 706-742-0082
  • Fax: 706-742-0083
Mailing address:
  • Phone: 724-728-7550
  • Fax: 724-728-6648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010676
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: