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General NPI Number Information
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NPI Number | 1184174161
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Entity Type | Organization
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Legal Business Name | 1SOURCE FITNESS & SPORTS NEURO REHAB
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Dates
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Enumeration Date | 10/13/2016
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Last Update Date | 10/13/2016
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Provider Practice Location Address
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Address Line | 4728 JOSEPH ELI DR
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City | SNELLVILLE
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State | GA
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Zip | 30039-7138
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Country | US
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Telephone | 678-257-4037
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Fax | 678-257-4037
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Provider Business Mailing Address
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Address Line | 4728 JOSEPH ELI DR
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City | SNELLVILLE
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State | GA
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Zip | 30039-7138
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Country | US
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Telephone | 678-257-4037
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Fax | 678-257-4037
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | COLLIN ADU
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Credential | DPT.GCS. MBA
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Telephone | 678-250-4035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 12002969
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License Number State | GA
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