Provider Demographics
NPI:1538101902
Name:JESSE L WIED PT PHYSICAL THERAPY CLINIC INC
Entity Type:Organization
Organization Name:JESSE L WIED PT PHYSICAL THERAPY CLINIC INC
Other - Org Name:WIED PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:CAGE
Authorized Official - Last Name:WIED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-322-7050
Mailing Address - Street 1:PO BOX 14151
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-4151
Mailing Address - Country:US
Mailing Address - Phone:318-322-7050
Mailing Address - Fax:318-322-7031
Practice Address - Street 1:1901 ROSELAWN AVE SUITE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-322-7050
Practice Address - Fax:318-322-7031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty