Basic Information
Provider Information | |||||||||
NPI: | 1073560595 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMPREHENSIVE BALANCE CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 121 TIVOLI ST | ||||||||
Address2: |   | ||||||||
City: | ABBEVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 705105150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3376529530 | ||||||||
FaxNumber: | 3372898970 | ||||||||
Practice Location | |||||||||
Address1: | 121 TIVOLI ST | ||||||||
Address2: |   | ||||||||
City: | ABBEVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 705105150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3376529530 | ||||||||
FaxNumber: | 3372898970 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2006 | ||||||||
LastUpdateDate: | 08/14/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DESORMEAUX | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 3376529530 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OTT.Z11169 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.