1033603519 NPI number — PHYSIOFIT PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033603519 NPI number — PHYSIOFIT PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSIOFIT PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHYSIOFIT - YOUNGSVILLE, LA
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033603519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6397 LEE HWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-2564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 LAFAYETTE ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-451-5947
Provider Business Practice Location Address Fax Number:
337-451-6219
Provider Enumeration Date:
06/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JOHANNESON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP REVENUE CYCLE OPERATIONS
Authorized Official Telephone Number:
423-238-2313

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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