Provider Demographics
NPI:1023202694
Name:EBERHARDT PHYSICAL THERAPY & WELLNESS CLINIC, INC.
Entity type:Organization
Organization Name:EBERHARDT PHYSICAL THERAPY & WELLNESS CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:REDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:318-222-7442
Mailing Address - Street 1:820 JORDAN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4529
Mailing Address - Country:US
Mailing Address - Phone:318-222-7442
Mailing Address - Fax:318-424-4751
Practice Address - Street 1:820 JORDAN ST STE 150
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4529
Practice Address - Country:US
Practice Address - Phone:318-222-7442
Practice Address - Fax:318-424-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX ID
LA5BC40Medicare PIN