=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255200416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENT & RESTORE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2025
-----------------------------------------------------
Last Update Date | 11/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 JOHNSON FERRY RD STE 2220
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-4948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-907-2734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2510 ROLLING VIEW DR SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-799-7343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FOUNDER
-----------------------------------------------------
Name | RAYMOND ALAN WATERS
-----------------------------------------------------
Credential | PT, DPT, CSCS
-----------------------------------------------------
Telephone | 706-799-7343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------