Provider Demographics
NPI:1043763337
Name:BEDORTHA, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BEDORTHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 METAIRIE ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:433 METAIRIE ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005
Practice Address - Country:US
Practice Address - Phone:504-835-7554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4687225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist