Provider Demographics
NPI:1184810426
Name:WELLNESS PHYSICAL THERAPY OF SLIDELL, LLC
Entity type:Organization
Organization Name:WELLNESS PHYSICAL THERAPY OF SLIDELL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-649-6577
Mailing Address - Street 1:1311 GAUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3015
Mailing Address - Country:US
Mailing Address - Phone:985-649-6577
Mailing Address - Fax:985-649-7615
Practice Address - Street 1:1311 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3015
Practice Address - Country:US
Practice Address - Phone:985-649-6577
Practice Address - Fax:985-649-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH8100OtherBLUE CROSS
LA5BD21Medicare PIN
LAH8100OtherBLUE CROSS