Provider Demographics
NPI:1366484719
Name:WELLNESS AEROBIC & SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:WELLNESS AEROBIC & SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-649-6577
Mailing Address - Street 1:1311 GAUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3015
Mailing Address - Country:US
Mailing Address - Phone:985-649-6577
Mailing Address - Fax:
Practice Address - Street 1:1311 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3015
Practice Address - Country:US
Practice Address - Phone:985-649-6577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CS21Medicare ID - Type Unspecified