=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427218106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE SPORTS PERFORMANCE WELLNESS AND REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2008
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 BECKETT LANE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-839-0841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 EAGLES LANDING WAY
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-839-0841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. TOLA O C AKOMOLAFE
-----------------------------------------------------
Credential | DPT MS CCI CEAS
-----------------------------------------------------
Telephone | 770-839-0841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT 04336
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------