1669821930 NPI number — WELLISTICS PHYSICAL THERAPY CENTER L3C

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 1669821930 NPI number — WELLISTICS PHYSICAL THERAPY CENTER L3C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLISTICS PHYSICAL THERAPY CENTER L3C
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:
1669821930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4228 WILLIAMS BLVD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065-2270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-224-8400
Provider Business Mailing Address Fax Number:
504-272-0237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4228 WILLIAMS BLVD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-2270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-224-8400
Provider Business Practice Location Address Fax Number:
504-272-0237
Provider Enumeration Date:
06/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
GRISELDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
504-224-8400

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669821930 . This is a "PHYSICAL THERAPY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1861848954 . This is a "PHYSICAL THERAPY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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