NPIMap

Organization Active NPI

Form Pelvic Health LLC

  • Physical Therapist
  • Roswell, GA
National Provider Identifier
1962275479
Registry record updated Nov 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
FORM PELVIC HEALTH LLC
Practice address
1295 Hembree Rd Ste A203
Roswell, GA 30076-4953
Phone
(678) 731-7772
Fax
(678) 731-7773
NPI assigned
Nov 6, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Blair A Holliday, PTNPI 1891001558
Title
Owner
Phone
(678) 936-0821

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X SINGLE SPECIALTY GROUP 225100000X Primary

Addresses

Primary practice location

1295 Hembree Rd Ste A203
Roswell, GA 30076-4953

Mailing address

1295 Hembree Rd Ste A203
Roswell, GA 30076-4953
Phone (678) 731-7772

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1699228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699228800000",
    "number": "1962275479",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1295 HEMBREE RD STE A203",
            "city": "ROSWELL",
            "state": "GA",
            "postal_code": "300764953",
            "telephone_number": "678-731-7772",
            "fax_number": "678-731-7773"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1295 HEMBREE RD STE A203",
            "city": "ROSWELL",
            "state": "GA",
            "postal_code": "300764953",
            "telephone_number": "678-731-7772",
            "fax_number": "678-731-7773"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORM PELVIC HEALTH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-06",
        "last_updated": "2023-11-06",
        "certification_date": "2023-11-03",
        "status": "A",
        "authorized_official_last_name": "HOLLIDAY",
        "authorized_official_first_name": "BLAIR",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "678-936-0821",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Roswell, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.