Provider Demographics
NPI:1568984581
Name:WAYNE, CORDARIUS (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:CORDARIUS
Middle Name:
Last Name:WAYNE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6947
Mailing Address - Country:US
Mailing Address - Phone:318-537-0280
Mailing Address - Fax:
Practice Address - Street 1:216 W UNION ST STE A
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3216
Practice Address - Country:US
Practice Address - Phone:318-299-6334
Practice Address - Fax:318-299-6332
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3001232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer