Provider Demographics
NPI:1093452930
Name:ETHREDGE, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:ETHREDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 AZALEA RD STE 11
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-9197
Mailing Address - Country:US
Mailing Address - Phone:912-705-2855
Mailing Address - Fax:
Practice Address - Street 1:401 E 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4624
Practice Address - Country:US
Practice Address - Phone:912-403-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist