Provider Demographics
NPI:1740494632
Name:NJALLE, RAYMOND MAURICE (PT)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:MAURICE
Last Name:NJALLE
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 1:1900 FALSE RIVER DR
Mailing Address - Street 2:#1
Mailing Address - City:NEW ROADS
Mailing Address - State:LA
Mailing Address - Zip Code:70760-2653
Mailing Address - Country:US
Mailing Address - Phone:225-638-6957
Mailing Address - Fax:
Practice Address - Street 1:344 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369
Practice Address - Country:US
Practice Address - Phone:318-941-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04007R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4CO19OtherMEDICARE PROVIDER #
LA5CB55Medicare ID - Type UnspecifiedMEDICARE NUMBER