Provider Demographics
NPI:1134204167
Name:FLEUR DE LIS PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:FLEUR DE LIS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILBURN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:504-943-8026
Mailing Address - Street 1:839 SPAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-7824
Mailing Address - Country:US
Mailing Address - Phone:504-943-8026
Mailing Address - Fax:
Practice Address - Street 1:839 SPAIN ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70117-7824
Practice Address - Country:US
Practice Address - Phone:504-943-8026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LANONE261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy