=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235515784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE PHILLIP ZIAYLEK JR. DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2015
-----------------------------------------------------
Last Update Date | 01/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 JOHNSON FERRY RD STE 340
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-6495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-491-7420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33900 HARPER AVE STE 104
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-350-2644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT012045
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------