MEDICARE: INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1982114278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PHYSICAL THERAPY OF GA, LLC

Provider Business Mailing Address
First Line	:	6397 LEE HWY STE 300
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2564
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	3919 CARTER RD # A
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-1628
Country	:	US
Telephone Number	:	888-628-5722
Fax Number	:	888-629-8994

Authorized Official
Title or Position	:	VP REVENUE CYCLE
Name	:	KEVIN JOHANNESON
Credential	:
Telephone Number	:	423-238-7217

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	10/02/2017

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