Provider Demographics
NPI:1285474759
Name:MIRANDA, ALFRED ALEXIS BALLEZA
Entity type:Individual
Prefix:
First Name:ALFRED ALEXIS
Middle Name:BALLEZA
Last Name:MIRANDA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:866-518-0283
Mailing Address - Fax:
Practice Address - Street 1:3007 PANOLA RD STE C
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2492
Practice Address - Country:US
Practice Address - Phone:770-987-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012126225100000X
225100000X
GAPT017569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist