Provider Demographics
NPI:1114154184
Name:THE EDGE PHYSICAL THERAPY AND SPORTS SCIENCE CENTER
Entity Type:Organization
Organization Name:THE EDGE PHYSICAL THERAPY AND SPORTS SCIENCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MEANS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:318-841-0696
Mailing Address - Street 1:2950 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-1906
Mailing Address - Country:US
Mailing Address - Phone:318-841-0696
Mailing Address - Fax:318-841-0776
Practice Address - Street 1:2950 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-1906
Practice Address - Country:US
Practice Address - Phone:318-841-0696
Practice Address - Fax:318-841-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07110R2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DK23Medicare PIN