Provider Demographics
NPI:1437646767
Name:PREMIER PERFORMANCE PHYSICAL THERAPY AND SPORTS REHAB
Entity Type:Organization
Organization Name:PREMIER PERFORMANCE PHYSICAL THERAPY AND SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:936-465-6282
Mailing Address - Street 1:192 LA-3226
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634
Mailing Address - Country:US
Mailing Address - Phone:936-465-6282
Mailing Address - Fax:
Practice Address - Street 1:243 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4105
Practice Address - Country:US
Practice Address - Phone:936-465-6282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09007R225100000X
LA08870R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty