Provider Demographics
NPI:1083761266
Name:AMITE PHYSICAL THERAPY DBA PROFESSIONAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:AMITE PHYSICAL THERAPY DBA PROFESSIONAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:985-748-7878
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-0398
Mailing Address - Country:US
Mailing Address - Phone:985-748-7878
Mailing Address - Fax:985-748-2837
Practice Address - Street 1:216 N 2ND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2408
Practice Address - Country:US
Practice Address - Phone:985-748-7878
Practice Address - Fax:985-748-2837
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMITE PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-03
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA140332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB89Medicare ID - Type UnspecifiedGROUP MEDICARE#