Provider Demographics
NPI:1861600520
Name:GENESIS SPORTS MEDICINE AND REHABILITATION, LLC
Entity type:Organization
Organization Name:GENESIS SPORTS MEDICINE AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:PT , CSCS
Authorized Official - Phone:404-290-1700
Mailing Address - Street 1:3890 REDWINE RD SW
Mailing Address - Street 2:SUITE 114
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5582
Mailing Address - Country:US
Mailing Address - Phone:404-344-7880
Mailing Address - Fax:404-344-7881
Practice Address - Street 1:3890 REDWINE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5582
Practice Address - Country:US
Practice Address - Phone:404-344-7880
Practice Address - Fax:404-344-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006133261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy