Provider Demographics
NPI:1962275479
Name:FORM PELVIC HEALTH LLC
Entity type:Organization
Organization Name:FORM PELVIC HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-936-0821
Mailing Address - Street 1:1295 HEMBREE RD STE A203
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4953
Mailing Address - Country:US
Mailing Address - Phone:678-731-7772
Mailing Address - Fax:678-731-7773
Practice Address - Street 1:1295 HEMBREE RD STE A203
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4953
Practice Address - Country:US
Practice Address - Phone:678-731-7772
Practice Address - Fax:678-731-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty