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General NPI Number Information
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NPI Number | 1194267260
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Entity Type | Organization
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Legal Business Name | SOVEREIGN REHABILITATION OF GEORGIA, LLC
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Dates
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Enumeration Date | 11/07/2016
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Last Update Date | 11/07/2016
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Provider Practice Location Address
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Address Line | 1301 SIGMAN RD NE SUITE 220
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City | CONYERS
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State | GA
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Zip | 30012-3812
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Country | US
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Telephone | 678-210-0311
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Fax | 678-210-0335
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Provider Business Mailing Address
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Address Line | 1301 SIGMAN RD NE SUITE 220
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City | CONYERS
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State | GA
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Zip | 30012-3812
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Country | US
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Telephone | 678-210-0311
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Fax | 678-210-0335
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Authorized Official
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Title or Position | VP OF OPERATIONS
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Name | COLETTE JOHNSON
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Credential |
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Telephone | 404-680-6470
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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 | PT008054
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License Number State | GA
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