Provider Demographics
NPI:1730293879
Name:ROLLINS, SHANE N (P T)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:N
Last Name:ROLLINS
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1594
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1594
Mailing Address - Country:US
Mailing Address - Phone:318-251-6103
Mailing Address - Fax:318-251-6141
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-251-6103
Practice Address - Fax:318-251-6141
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1006858Medicaid
LA1599085OtherLA PROVIDER #
KY5CR78Medicare ID - Type Unspecified
LA4H594CR78Medicare UPIN