Basic Information
| Provider Information | |||||||||
| NPI: | 1255435616 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENT PHYSICAL THERAPY OF GA LLC | ||||||||
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| OtherOrganizationName: | BENCHMARK PT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LANE | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 STATE HIGHWAY 17 STE 9 | ||||||||
| Address2: | |||||||||
| City: | YOUNG HARRIS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305821880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068962771 | ||||||||
| FaxNumber: | 7068962772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/15/2006 | ||||||||
| NPIReactivationDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4232387217 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.