Provider Demographics
NPI:1649276197
Name:PERFORMANCE PHYSICAL THERAPY OF MINDEN, L.L.C.
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF MINDEN, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:DON
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:318-371-6666
Mailing Address - Street 1:906 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3024
Mailing Address - Country:US
Mailing Address - Phone:318-371-6666
Mailing Address - Fax:318-371-9966
Practice Address - Street 1:906 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3024
Practice Address - Country:US
Practice Address - Phone:318-371-6666
Practice Address - Fax:318-371-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT306R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112810Medicaid
LA4C050Medicare PIN