Provider Demographics
NPI:1366971277
Name:PARK RIDGE HEALTHCARE AND PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:PARK RIDGE HEALTHCARE AND PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SALLARULO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-457-0584
Mailing Address - Street 1:2896 CHAMBLEE TUCKER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4009
Mailing Address - Country:US
Mailing Address - Phone:770-457-0584
Mailing Address - Fax:770-457-0773
Practice Address - Street 1:2896 CHAMBLEE TUCKER ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-457-0584
Practice Address - Fax:770-457-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X
GACHIR002472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty