Provider Demographics
NPI:1215123955
Name:SEJONG PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:SEJONG PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-206-0808
Mailing Address - Street 1:1325 SATELLITE BLVD NW
Mailing Address - Street 2:STE.1302
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4651
Mailing Address - Country:US
Mailing Address - Phone:678-206-0808
Mailing Address - Fax:678-206-0809
Practice Address - Street 1:1325 SATELLITE BLVD NW
Practice Address - Street 2:STE.1302
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4651
Practice Address - Country:US
Practice Address - Phone:678-206-0808
Practice Address - Fax:678-206-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008581225100000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA360461626BMedicaid
GA511G700043Medicare PIN
GA6215540001Medicare NSC