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General NPI Number Information
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NPI Number | 1982874863
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Entity Type | Organization
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Legal Business Name | PHYSIOEDGE, LLC
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Dates
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Enumeration Date | 03/06/2008
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Last Update Date | 03/23/2012
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Provider Practice Location Address
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Address Line | 670 NORTH AVE NW SUITE 201
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City | MARIETTA
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State | GA
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Zip | 30060-1100
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Country | US
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Telephone | 770-792-8081
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Fax | 770-792-8083
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Provider Business Mailing Address
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Address Line | 223 MILLSTONE PKWY
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City | WOODSTOCK
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State | GA
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Zip | 30188-6139
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Country | US
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Telephone | 404-771-0554
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Fax | 770-792-8083
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Authorized Official
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Title or Position | OWNER
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Name | MR. AL WYNNE QUERUBIN GESITE
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Credential | P.T.
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Telephone | 404-771-0554
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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 |
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License Number State |
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