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General NPI Number Information
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NPI Number | 1417178633
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Entity Type | Organization
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Legal Business Name | GEORGIA TECH SPORTS MEDICINE AND REHAB
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 150 BOBBY DODD WAY
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City | ATLANTA
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State | GA
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Zip | 30332-0001
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Country | US
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Telephone | 404-385-4115
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Fax | 404-894-0695
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Provider Business Mailing Address
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Address Line | 150 BOBBY DODD WAY
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City | ATLANTA
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State | GA
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Zip | 30332-0001
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Country | US
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Telephone | 404-385-4115
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Fax | 404-894-0695
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Authorized Official
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Title or Position | PHYSICAL THERAPIST CLINIC DIRECTOR
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Name | MR. CHARLIE RIDGEWAY
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Credential | BS, PT
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Telephone | 404-385-4115
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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 | 6601
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License Number State | GA
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