Basic Information
| Provider Information | |||||||||
| NPI: | 1184810426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLNESS PHYSICAL THERAPY OF SLIDELL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLNESS PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 GAUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856496577 | ||||||||
| FaxNumber: | 9856497615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 GAUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856496577 | ||||||||
| FaxNumber: | 9856497615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARRON | ||||||||
| AuthorizedOfficialFirstName: | JERI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9856496577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 06166 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | H8100 | 01 | LA | BLUE CROSS | OTHER |