Provider Demographics
NPI:1790809028
Name:XTREME PHYSICAL THERAPY
Entity Type:Organization
Organization Name:XTREME PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:504-374-0015
Mailing Address - Street 1:3300 BEHRMAN PL
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8215
Mailing Address - Country:US
Mailing Address - Phone:504-374-0015
Mailing Address - Fax:504-374-0016
Practice Address - Street 1:3300 BEHRMAN PL
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-8215
Practice Address - Country:US
Practice Address - Phone:504-374-0015
Practice Address - Fax:504-374-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1179701Medicaid
LA5CF61Medicare ID - Type UnspecifiedPART B