Provider Demographics
NPI:1104080266
Name:SOUTH GEORGIA THERAPY SERVICES, P.C.
Entity type:Organization
Organization Name:SOUTH GEORGIA THERAPY SERVICES, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/P.T.
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:DURRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:912-654-2385
Mailing Address - Street 1:104 W RUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-1805
Mailing Address - Country:US
Mailing Address - Phone:912-654-2385
Mailing Address - Fax:912-654-2394
Practice Address - Street 1:104 W RUSTIN ST
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-1805
Practice Address - Country:US
Practice Address - Phone:912-654-2385
Practice Address - Fax:912-654-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA161037534AMedicaid
GA65BBDVSMedicare PIN