Provider Demographics
NPI:1356319552
Name:PREMIER REHAB & AQUATICS
Entity Type:Organization
Organization Name:PREMIER REHAB & AQUATICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:VINCE
Authorized Official - Last Name:TASSIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:985-893-8285
Mailing Address - Street 1:7015 HWY 190 E SERV RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4960
Mailing Address - Country:US
Mailing Address - Phone:985-893-8285
Mailing Address - Fax:985-893-8288
Practice Address - Street 1:7015 HWY 190 E SERV RD
Practice Address - Street 2:SUITE 103
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4960
Practice Address - Country:US
Practice Address - Phone:985-893-8285
Practice Address - Fax:985-893-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CQ01Medicare ID - Type Unspecified