Provider Demographics
NPI:1689707564
Name:PHYSIOFIT LLC
Entity Type:Organization
Organization Name:PHYSIOFIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTGERUS
Authorized Official - Middle Name:FJ
Authorized Official - Last Name:JONGBLOETS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:985-532-9662
Mailing Address - Street 1:115 JOHNNY DUFRENE DR
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-2611
Mailing Address - Country:US
Mailing Address - Phone:985-532-9662
Mailing Address - Fax:985-532-3942
Practice Address - Street 1:18641 HWY 3235
Practice Address - Street 2:
Practice Address - City:GALLIANO
Practice Address - State:LA
Practice Address - Zip Code:70354
Practice Address - Country:US
Practice Address - Phone:985-475-4555
Practice Address - Fax:985-475-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5233772261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CU46Medicare ID - Type UnspecifiedPT OT OUTPATIENT CLINIC
LA6374040002Medicare NSC