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General NPI Number Information
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NPI Number | 1558853085
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Entity Type | Organization
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Legal Business Name | RE GENERATE PHYSIOTHERAPY, LLC
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/31/2018
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Provider Practice Location Address
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Address Line | 1240 GA-54 BUILDING 700
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City | FAYETTEVILLE
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State | GA
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Zip | 30214
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Country | US
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Telephone | 678-506-0196
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Fax | 706-611-0436
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Provider Business Mailing Address
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Address Line | 250 ESSEX CIRCLE
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City | FAYETTEVILLE
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State | GA
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Zip | 30215
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Country | US
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Telephone | 678-506-0196
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Fax | 706-661-0436
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Authorized Official
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Title or Position | BUSINESS OWNER/PHYSICAL THERAPIST
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Name | DR. JENNIFER MCGOWAN
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Credential | PT, DPT, OCS
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Telephone | 678-506-0196
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT011852
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License Number State | GA
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