MEDICARE: BRENAU REHABILITATION PRACTICE GAINESVILLEPHYSICAL THERAPY

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	57446	GA

General Provider Information

NPI Number	:	1932571189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENAU REHABILITATION PRACTICE GAINESVILLEPHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	1296 SIMS STREET
Second Line	:	SUITE A
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3850
Country	:	US
Telephone Number	:	770-297-1700
Fax Number	:	770-297-1702

Provider Business Practice Location Address
First Line	:	301 MAIN ST SW
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3777
Country	:	US
Telephone Number	:	770-297-1700
Fax Number	:	770-297-1702

Authorized Official
Title or Position	:	OWNER
Name	:	VICKI SIMS
Credential	:	PT
Telephone Number	:	770-297-1700

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	10/28/2015

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