Provider Demographics
NPI:1679053805
Name:CHUKWUMA, SAMUEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CHUKWUMA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1498 HUDSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5018
Practice Address - Country:US
Practice Address - Phone:678-289-0525
Practice Address - Fax:678-289-0529
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT013599OtherGEORGIA SECRETARY OF STATE PROFESSIONAL LICENSING BOARDS