Provider Demographics
NPI:1124245295
Name:DEKALBPHYSICAL THERAPY
Entity type:Organization
Organization Name:DEKALBPHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-297-9330
Mailing Address - Street 1:5462 MEMORIAL DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STONE MTN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3239
Mailing Address - Country:US
Mailing Address - Phone:770-491-1353
Mailing Address - Fax:404-297-9329
Practice Address - Street 1:5462 MEMORIAL DR
Practice Address - Street 2:SUITE 203
Practice Address - City:STONE MTN
Practice Address - State:GA
Practice Address - Zip Code:30083-3239
Practice Address - Country:US
Practice Address - Phone:770-491-1353
Practice Address - Fax:770-723-9653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-6512Medicare ID - Type Unspecified