Provider Demographics
NPI:1528616190
Name:SOUTHERN PELVIC HEALTH, LLC
Entity type:Organization
Organization Name:SOUTHERN PELVIC HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:REALE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:719-429-6371
Mailing Address - Street 1:300 SOMERSET LN SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4310
Mailing Address - Country:US
Mailing Address - Phone:719-429-6371
Mailing Address - Fax:
Practice Address - Street 1:601 WOODLAWN DR NE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-3504
Practice Address - Country:US
Practice Address - Phone:770-415-4815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy