1689707564 NPI number — PHYSIOFIT LLC

Table of content: (NPI 1689707564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689707564 NPI number — PHYSIOFIT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSIOFIT 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:
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:
1689707564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 JOHNNY DUFRENE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RACELAND
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70394-2611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-532-9662
Provider Business Mailing Address Fax Number:
985-532-3942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18641 HWY 3235
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLIANO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-475-4555
Provider Business Practice Location Address Fax Number:
985-475-4557
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONGBLOETS
Authorized Official First Name:
RUTGERUS
Authorized Official Middle Name:
FJ
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
985-532-9662

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  5233772 , 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)





Copyright © 2007-2025 www.npivalidator.com