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General NPI Number Information
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NPI Number | 1134936982
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Entity Type | Individual
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Provider Name | SIMON CHANG PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 2456 SUMMEROAK DR
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City | TUCKER
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State | GA
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Zip | 30084-3453
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Country | US
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Telephone | 706-810-0065
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Fax |
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Provider Business Mailing Address
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Address Line | 2887 MALTON WAY
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City | LOGANVILLE
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State | GA
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Zip | 30052-1112
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Country | US
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Telephone | 770-231-5842
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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 | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT016743
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License Number State | GA
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