Basic Information
| Provider Information | |||||||||
| NPI: | 1922401264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLONIAL REHABILITATION GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Practice Location | |||||||||
| Address1: | 7101 JAHNKE RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043203911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | DURHAM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7708745400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.