Provider Demographics
NPI:1770630931
Name:FAUST, OWEN JAMES (PT)
Entity Type:Individual
Prefix:PROF
First Name:OWEN
Middle Name:JAMES
Last Name:FAUST
Suffix:
Gender:M
Credentials:PT
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 398
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-0398
Mailing Address - Country:US
Mailing Address - Phone:985-748-7878
Mailing Address - Fax:985-748-2837
Practice Address - Street 1:216 N 2ND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2408
Practice Address - Country:US
Practice Address - Phone:985-748-7878
Practice Address - Fax:985-748-2837
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB89Medicare ID - Type UnspecifiedGROUP MEDICARE#