Provider Demographics
NPI:1770628141
Name:BAKER PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:BAKER PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:225-775-7051
Mailing Address - Street 1:4971 GROOM RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-3145
Mailing Address - Country:US
Mailing Address - Phone:225-775-7051
Mailing Address - Fax:225-774-7244
Practice Address - Street 1:4971 GROOM RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3145
Practice Address - Country:US
Practice Address - Phone:225-775-7051
Practice Address - Fax:225-774-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT-0307261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA23651OtherBLUE CROSS PROVIDER #
LA23651OtherBLUE CROSS PROVIDER #