Provider Demographics
NPI:1003080367
Name:BEAUREGARD PHYSICAL THERAPY CLINIC, INC
Entity Type:Organization
Organization Name:BEAUREGARD PHYSICAL THERAPY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMEY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:337-462-6097
Mailing Address - Street 1:309 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4861
Mailing Address - Country:US
Mailing Address - Phone:337-462-6097
Mailing Address - Fax:337-462-0531
Practice Address - Street 1:309 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4861
Practice Address - Country:US
Practice Address - Phone:337-462-6097
Practice Address - Fax:337-462-0531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPT06472OtherLA PHYSICAL THERAPY BOARD