MEDICARE: BACK TO ACTION SPORTS REHAB, LLC.

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
1	225100000X	Physical Therapist	PT011203	GA

General Provider Information

NPI Number	:	1477987568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO ACTION SPORTS REHAB, LLC.

Provider Business Mailing Address
First Line	:	4936 GREEN POINTE WAY NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-1506
Country	:	US
Telephone Number	:	410-688-3708
Fax Number	:

Provider Business Practice Location Address
First Line	:	754 PEACHTREE ST NE
Second Line	:	SUITE 105
City	:	ATLANTA
State	:	GA
Zip	:	30308-1206
Country	:	US
Telephone Number	:	410-688-3708
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAMAR B. FRASIER
Credential	:	DPT
Telephone Number	:	410-688-3708

Provider Enumeration Date	:	08/26/2013
Last Update Date	:	04/08/2014

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