Provider Demographics
NPI:1558580696
Name:ALL SOUTH PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ALL SOUTH PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:ADAMS
Authorized Official - Last Name:BONURA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:504-909-8773
Mailing Address - Street 1:5624 ERLANGER RD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-1564
Mailing Address - Country:US
Mailing Address - Phone:504-301-1310
Mailing Address - Fax:504-466-6367
Practice Address - Street 1:5624 ERLANGER RD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-1564
Practice Address - Country:US
Practice Address - Phone:504-301-1310
Practice Address - Fax:504-466-6367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068128Medicaid