=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346049848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PT AT HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 CROWN MOUNTAIN PL UNIT A300
-----------------------------------------------------
City | DAHLONEGA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30533-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-540-2637
-----------------------------------------------------
Fax | 706-867-6859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 CROWN MOUNTAIN PL UNIT A300
-----------------------------------------------------
City | DAHLONEGA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30533-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-540-2637
-----------------------------------------------------
Fax | 706-867-6859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/ OWNER
-----------------------------------------------------
Name | MANDY RIANNA VANDER POL
-----------------------------------------------------
Credential | P.T., M.S., D.P.T.
-----------------------------------------------------
Telephone | 770-540-2637
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------