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Organization
CEDAR GROVE REHAB LLC
Active
Organization
CEDAR GROVE REHAB LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. OTIS L BONNER III (ATTORNEY)
(770) 940-4975
Entity
Organization
Contact information
Practice address
3395 BOULDERCREST RD, ELLENWOOD, GA 30294-1639
(404) 241-3280
Mailing address
3395 BOULDERCREST RD, ELLENWOOD, GA 30294-1639
(404) 241-3280
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
—
NULL
111N00000X
Chiropractor
—
—
208100000X
Physical Medicine & Rehabilitation Physician
Primary
—
NULL
208100000X
Physical Medicine & Rehabilitation Physician
Primary
—
—
363A00000X
Physician Assistant
—
NULL
363A00000X
Physician Assistant
—
—
Other
Enumeration date
04/30/2013
Last updated
04/30/2013
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