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General NPI Number Information
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NPI Number | 1104545094
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Entity Type | Individual
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Provider Name | MARCO WILLIAM BALLETTO JR.
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Gender | Male
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 08/24/2022
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Provider Practice Location Address
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Address Line | 855 EMORY POINT DR STE C-130
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City | ATLANTA
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State | GA
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Zip | 30329-4022
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Country | US
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Telephone | 678-553-9466
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 CIRCLE 75 PKWY SE STE 1400
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City | ATLANTA
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State | GA
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Zip | 30339-3067
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PT016159
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License Number State | GA
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