Provider Demographics
NPI:1699743211
Name:RICH, JUSTIN B (MPT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:B
Last Name:RICH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MIRROR LAKE BLVD STE S
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-2126
Mailing Address - Country:US
Mailing Address - Phone:770-456-7877
Mailing Address - Fax:770-456-7880
Practice Address - Street 1:2000 MIRROR LAKE BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-2124
Practice Address - Country:US
Practice Address - Phone:770-456-7877
Practice Address - Fax:770-456-7880
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA205150275Medicaid