Provider Demographics
NPI:1629291976
Name:MCBRIDE, KEVIN (PTA)
Entity Type:Individual
Prefix:PROF
First Name:KEVIN
Middle Name:
Last Name:MCBRIDE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W PINHOOK RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2131
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-942-9979
Practice Address - Street 1:4027 I 49 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0757
Practice Address - Country:US
Practice Address - Phone:337-948-4212
Practice Address - Fax:337-942-9979
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA6584225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA710917927OtherTAX ID#
LAA6584OtherPTA LICENCE #