Provider Demographics
NPI:1952471252
Name:VIDRINE, DAVID L (P T)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:VIDRINE
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 1:1477 W LASALLE ST
Mailing Address - Street 2:
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586-2974
Mailing Address - Country:US
Mailing Address - Phone:337-363-2600
Mailing Address - Fax:337-363-2599
Practice Address - Street 1:1477 W LASALLE ST
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586-2974
Practice Address - Country:US
Practice Address - Phone:337-363-2600
Practice Address - Fax:337-363-2599
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1153591Medicaid
LA1153591Medicaid