Basic Information
| Provider Information | |||||||||
| NPI: | 1194147215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESOP REHABILITATION, LLC | ||||||||
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| OtherOrganizationName: | EMORY & SELECT PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG ROAD | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Practice Location | |||||||||
| Address1: | 1435 N EXPRESSWAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302231700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702274049 | ||||||||
| FaxNumber: | 7704127009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2014 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.