=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982887543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO HEALTH AND REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 12/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2453 POWDER SPRINGS RD SW SUITE 215
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-567-2313
-----------------------------------------------------
Fax | 855-771-9101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2453 POWDER SPRINGS RD SW SUITE 215
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-567-2313
-----------------------------------------------------
Fax | 855-771-9101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PROVIDER
-----------------------------------------------------
Name | STEFAN CHARLES G SABOURA
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 678-567-2313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 39009
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083P0500X
-----------------------------------------------------
Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
-----------------------------------------------------
License Number | 68404
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | RN191854
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | CHIR006384
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------