Provider Demographics
NPI:1376216788
Name:FIRM FOUNDATION PEDIATRIC THER
Entity Type:Organization
Organization Name:FIRM FOUNDATION PEDIATRIC THER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:318-224-9081
Mailing Address - Street 1:683 ROACH RD
Mailing Address - Street 2:
Mailing Address - City:CHOUDRANT
Mailing Address - State:LA
Mailing Address - Zip Code:71227-3630
Mailing Address - Country:US
Mailing Address - Phone:318-918-0756
Mailing Address - Fax:
Practice Address - Street 1:1316 E KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6609
Practice Address - Country:US
Practice Address - Phone:318-224-9081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-30
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1884600Medicaid