Provider Demographics
NPI:1982874863
Name:PHYSIOEDGE, LLC
Entity type:Organization
Organization Name:PHYSIOEDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AL WYNNE
Authorized Official - Middle Name:QUERUBIN
Authorized Official - Last Name:GESITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:404-771-0554
Mailing Address - Street 1:223 MILLSTONE PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6139
Mailing Address - Country:US
Mailing Address - Phone:404-771-0554
Mailing Address - Fax:770-792-8083
Practice Address - Street 1:670 NORTH AVE NW
Practice Address - Street 2:SUITE 201
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1100
Practice Address - Country:US
Practice Address - Phone:770-792-8081
Practice Address - Fax:770-792-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy