Provider Demographics
NPI:1275823320
Name:CALCASIEU REHAB AND SPORTS THERAPY
Entity Type:Organization
Organization Name:CALCASIEU REHAB AND SPORTS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:337-217-0997
Mailing Address - Street 1:2100 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7864
Mailing Address - Country:US
Mailing Address - Phone:337-310-5116
Mailing Address - Fax:337-310-5118
Practice Address - Street 1:217 SAM HOUSTON JONES PKWY STE 103
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5644
Practice Address - Country:US
Practice Address - Phone:337-217-0997
Practice Address - Fax:337-217-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DR53Medicare PIN