Provider Demographics
NPI:1265799761
Name:XTREME PHYSICAL THERAPY EAST
Entity type:Organization
Organization Name:XTREME PHYSICAL THERAPY EAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:504-374-0015
Mailing Address - Street 1:5555 BULLARD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70128-3450
Mailing Address - Country:US
Mailing Address - Phone:504-374-0015
Mailing Address - Fax:504-374-0016
Practice Address - Street 1:5555 BULLARD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70128-3450
Practice Address - Country:US
Practice Address - Phone:504-374-0015
Practice Address - Fax:504-374-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty