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General NPI Number Information
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NPI Number | 1477987568
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Entity Type | Organization
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Legal Business Name | BACK TO ACTION SPORTS REHAB, LLC.
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Dates
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Enumeration Date | 08/26/2013
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Last Update Date | 04/08/2014
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Provider Practice Location Address
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Address Line | 754 PEACHTREE ST NE SUITE 105
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City | ATLANTA
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State | GA
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Zip | 30308-1206
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Country | US
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Telephone | 410-688-3708
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Fax |
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Provider Business Mailing Address
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Address Line | 4936 GREEN POINTE WAY NE
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City | MARIETTA
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State | GA
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Zip | 30067-1506
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Country | US
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Telephone | 410-688-3708
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LAMAR B. FRASIER
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Credential | DPT
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Telephone | 410-688-3708
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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 | PT011203
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License Number State | GA
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