Provider Demographics
NPI:1699909671
Name:PHYSICAL THERAPY HOME HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY HOME HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:V
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-288-2688
Mailing Address - Street 1:120 PINNACLE LN
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2057
Mailing Address - Country:US
Mailing Address - Phone:770-288-2688
Mailing Address - Fax:770-288-2341
Practice Address - Street 1:120 PINNACLE LN
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-2057
Practice Address - Country:US
Practice Address - Phone:770-288-2688
Practice Address - Fax:770-288-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08042527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA255095737AMedicaid
GA511G701299Medicare PIN