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General NPI Number Information
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NPI Number | 1104080266
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Entity Type | Organization
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Legal Business Name | SOUTH GEORGIA THERAPY SERVICES, P.C.
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Dates
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Enumeration Date | 07/17/2008
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 104 W RUSTIN ST
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City | GLENNVILLE
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State | GA
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Zip | 30427-1805
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Country | US
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Telephone | 912-654-2385
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Fax | 912-654-2394
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Provider Business Mailing Address
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Address Line | 104 W RUSTIN ST
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City | GLENNVILLE
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State | GA
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Zip | 30427-1805
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Country | US
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Telephone | 912-654-2385
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Fax | 912-654-2394
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Authorized Official
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Title or Position | OWNER/P.T.
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Name | MR. KENNETH LANE DURRENCE
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Credential | P.T.
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Telephone | 912-654-2385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT003337
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License Number State | GA
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