Provider Demographics
NPI:1245259290
Name:PRINCE, RAYMOND E JR (DPT)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:E
Last Name:PRINCE
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 S BEGLIS PKWY
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-8120
Mailing Address - Country:US
Mailing Address - Phone:337-558-5949
Mailing Address - Fax:
Practice Address - Street 1:223 S RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5974
Practice Address - Country:US
Practice Address - Phone:337-721-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H793Medicare ID - Type Unspecified