1124138573 NPI number — LOUISIANA THERAPY AND WELLNESS CENTER

Table of content: (NPI 1124138573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124138573 NPI number — LOUISIANA THERAPY AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISIANA THERAPY AND WELLNESS CENTER
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:
Provider Other Organization Name Type Code:
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:
1124138573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 SHORTCUT HWY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SLIDELL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70458-8047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-641-3818
Provider Business Mailing Address Fax Number:
985-641-3891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 SHORTCUT HWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70458-8047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-641-3818
Provider Business Practice Location Address Fax Number:
985-641-3891
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRAHAN
Authorized Official First Name:
JANE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PTA, ADMINISTRATOR/OWNER
Authorized Official Telephone Number:
985-641-3818

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225200000X , with the licence number: A1975G , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XH1200X , with the licence number: OTT.Z12066 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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