1538101902 NPI number — JESSE L WIED PT PHYSICAL THERAPY CLINIC INC

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 1538101902 NPI number — JESSE L WIED PT PHYSICAL THERAPY CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSE L WIED PT PHYSICAL THERAPY CLINIC INC
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:
6
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:
1538101902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71207-4151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-322-7050
Provider Business Mailing Address Fax Number:
318-322-7031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 ROSELAWN AVE SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-322-7050
Provider Business Practice Location Address Fax Number:
318-322-7031
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIED
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
CAGE
Authorized Official Title or Position:
SECRETARY TREASURER
Authorized Official Telephone Number:
318-322-7050

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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