Healthcare Provider Details

I. General information

NPI: 1457545170
Provider Name (Legal Business Name): LILA FRAZER RALSTON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LILA FRANCES FRAZER

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MOORES GROVE RD SUITE 100
WINTERVILLE GA
30683-1506
US

IV. Provider business mailing address

104 MOORES GROVE RD SUITE 100
WINTERVILLE GA
30683-1506
US

V. Phone/Fax

Practice location:
  • Phone: 706-742-0082
  • Fax:
Mailing address:
  • Phone: 706-742-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002401
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: