Organization
FORM PHYSICAL THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BLAIR HOLLIDAY MPT (OWNER)
(678) 936-0821
Entity
Organization
Contact information
Practice address
1295 HEMBREE RD STE A201, ROSWELL, GA 30076
(678) 936-0821
Mailing address
4005 DOVER AVE, ALPHARETTA, GA 30009-3283
(678) 936-0821
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT008864
GA
Other
Enumeration date
05/07/2018
Last updated
05/12/2018
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