Provider Demographics
NPI:1407322357
Name:RELLE, MICHAEL STEPHEN (CPO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:RELLE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HIGHLAND PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7128
Mailing Address - Country:US
Mailing Address - Phone:985-898-6319
Mailing Address - Fax:985-867-8803
Practice Address - Street 1:101 HIGHLAND PARK PLZ
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7128
Practice Address - Country:US
Practice Address - Phone:985-898-6319
Practice Address - Fax:985-867-8803
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACPO2891OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, AND PEDORTHOTICS