=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114788627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN POE PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2024
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 HOMER RD
-----------------------------------------------------
City | COMMERCE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30529-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-335-3816
-----------------------------------------------------
Fax | 706-335-3819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1660 WASHINGTON ST
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30549-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-367-1898
-----------------------------------------------------
Fax | 706-367-1899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 001950
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------