Provider Demographics
NPI:1457996316
Name:MCENTIRE, CALEB T (PT)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:T
Last Name:MCENTIRE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5795 N MARKET ST STE 8
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2527
Mailing Address - Country:US
Mailing Address - Phone:318-489-4298
Mailing Address - Fax:318-489-4299
Practice Address - Street 1:5795 N MARKET ST STE 8
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2527
Practice Address - Country:US
Practice Address - Phone:318-489-4298
Practice Address - Fax:318-489-4299
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09908OtherLA BOARD OF PHYSICAL THERAPY EXAMINERS