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NPI Code Detail

MEDICARE: HAYWARD WHITE JR. LPTA

MEDICARE: HAYWARD WHITE JR. LPTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantPTA000054GA

General Provider Information

NPI Number : 1215278858
Entity Type Code : Individual
Provider Name (Legal Business Name) : HAYWARD WHITE JR. LPTA
Provider Business Mailing Address
First Line : 318 YOUNG JAMES CIR
Second Line :
City : STOCKBRIDGE
State : GA
Zip : 30281-1469
Country : US
Telephone Number : 678-887-6644
Fax Number : 678-284-1699
Provider Business Practice Location Address
First Line : 315 UPPER RIVERDALE RD SW
Second Line :
City : RIVERDALE
State : GA
Zip : 30274-2500
Country : US
Telephone Number : 770-991-2636
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/06/2013
Last Update Date : 03/06/2013

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