=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831355601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARCHER PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2008
-----------------------------------------------------
Last Update Date | 08/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3012 LAFAYETTE RD
-----------------------------------------------------
City | FORT OGLETHORPE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30742-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-693-5490
-----------------------------------------------------
Fax | 678-349-0693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2031
-----------------------------------------------------
City | FORT OGLETHORPE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30742-0031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-693-5490
-----------------------------------------------------
Fax | 678-349-0693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | DEBRA ELIZABETH MARTIN
-----------------------------------------------------
Credential | M.S.P.T., MLD/CDT
-----------------------------------------------------
Telephone | 423-693-5490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT004654
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------