=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578908596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2013
-----------------------------------------------------
Last Update Date | 05/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 COLUMBUS RD
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-592-4778
-----------------------------------------------------
Fax | 740-592-2244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 E CANAL ST
-----------------------------------------------------
City | NELSONVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45764-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-753-4567
-----------------------------------------------------
Fax | 740-592-2244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JEROMY SCHULTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 740-592-4778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-011149
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------