Provider Demographics
NPI:1700973054
Name:LIFESPAN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LIFESPAN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IME
Authorized Official - Middle Name:E
Authorized Official - Last Name:UDOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, PHD, FCCWS
Authorized Official - Phone:985-594-8332
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:CHAUVIN
Mailing Address - State:LA
Mailing Address - Zip Code:70344-0058
Mailing Address - Country:US
Mailing Address - Phone:985-594-8332
Mailing Address - Fax:985-594-8389
Practice Address - Street 1:5108 HWY 56
Practice Address - Street 2:
Practice Address - City:CHAUVIN
Practice Address - State:LA
Practice Address - Zip Code:70344
Practice Address - Country:US
Practice Address - Phone:985-594-8332
Practice Address - Fax:985-594-8389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C898Medicare ID - Type Unspecified