Healthcare Provider Details

I. General information

NPI: 1669734554
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

IV. Provider business mailing address

4959 BILL GARDNER PKWY STE 109
LOCUST GROVE GA
30248-2915
US

V. Phone/Fax

Practice location:
  • Phone: 423-238-7217
  • Fax: 423-238-3473
Mailing address:
  • Phone: 770-914-9285
  • Fax: 770-914-5668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KILEY RUSSELL
Title or Position: MANAGER
Credential:
Phone: 423-238-8923