Provider Demographics
NPI:1801157052
Name:TRIUMPH REHABILITATION AND SPORTS THERAPY CLINIC, LLC
Entity type:Organization
Organization Name:TRIUMPH REHABILITATION AND SPORTS THERAPY CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:318-343-1870
Mailing Address - Street 1:PO BOX 9144
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-9144
Mailing Address - Country:US
Mailing Address - Phone:318-343-1870
Mailing Address - Fax:318-345-2862
Practice Address - Street 1:350 DESIARD PLAZA DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-4959
Practice Address - Country:US
Practice Address - Phone:318-343-1870
Practice Address - Fax:318-345-2862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1434957Medicaid