Provider Demographics
NPI:1033138953
Name:CORE WELLNESS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CORE WELLNESS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WESSELS
Authorized Official - Suffix:
Authorized Official - Credentials:PT,CFT
Authorized Official - Phone:318-340-9877
Mailing Address - Street 1:408 NORTH SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4102
Mailing Address - Country:US
Mailing Address - Phone:318-340-9877
Mailing Address - Fax:318-340-9879
Practice Address - Street 1:408 N 6TH ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4102
Practice Address - Country:US
Practice Address - Phone:318-340-9877
Practice Address - Fax:318-340-9879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0600002566174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherFEDERAL TAX ID NUMBER