# CEDAR GROVE REHAB LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1255776613
- **Authorized official:** MR. OTIS L BONNER III (ATTORNEY)
- **Authorized official phone:** (770) 940-4975

## Contact information

- **Practice address:** 3395 BOULDERCREST RD, ELLENWOOD, GA 30294-1639
- **Practice address phone:** (404) 241-3280
- **Mailing address:** 3395 BOULDERCREST RD, ELLENWOOD, GA 30294-1639
- **Mailing address phone:** (404) 241-3280

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | — | NULL | — |
| 111N00000X | Chiropractor | — | — | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 04/30/2013
- **Last updated:** 04/30/2013