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General NPI Number Information
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NPI Number | 1750528303
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Entity Type | Organization
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Legal Business Name | PROACTIVE PHYSICAL THERAPY, INC.
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Dates
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Enumeration Date | 01/17/2009
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Last Update Date | 01/17/2009
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Provider Practice Location Address
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Address Line | 4625 ALEXANDER DR SUITE 115
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City | ALPHARETTA
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State | GA
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Zip | 30022-3719
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Country | US
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Telephone | 404-247-0174
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Fax |
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Provider Business Mailing Address
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Address Line | 1360 BELLSMITH DR
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City | ROSWELL
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State | GA
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Zip | 30076-0915
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Country | US
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Telephone | 404-247-0174
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Fax |
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Authorized Official
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Title or Position | OWNER/PT
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Name | MRS. ANGELA NICOLE FOWLER
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Credential | PT
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Telephone | 404-247-0174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT008404
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License Number State | GA
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