=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922379189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1SOURCE FITNESS & SPORTS-NEURO REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2012
-----------------------------------------------------
Last Update Date | 03/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 MCKENDREE CHURCH RD STE 40
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-257-4037
-----------------------------------------------------
Fax | 678-819-7536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1670 MCKENDREE CHURCH RD STE 40
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-257-4037
-----------------------------------------------------
Fax | 678-819-7536
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR. OF PHYSICAL THERAPY
-----------------------------------------------------
Name | DR. COLLIN ADU
-----------------------------------------------------
Credential | DPT.MBA.FAAOMPT
-----------------------------------------------------
Telephone | 678-257-4037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT009750
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------