MEDICARE: GARY NEIL BORDELON LPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	LAPT 01633	LA

General Provider Information

NPI Number	:	1528120011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY NEIL BORDELON LPT

Provider Business Mailing Address
First Line	:	PO BOX 250
Second Line	:	235 CANAL STREET
City	:	ARNAUDVILLE
State	:	LA
Zip	:	70512
Country	:	US
Telephone Number	:	337-754-7777
Fax Number	:	337-754-7773

Provider Business Practice Location Address
First Line	:	235 CANAL STREET
Second Line	:
City	:	ARNAUDVILLE
State	:	LA
Zip	:	70512
Country	:	US
Telephone Number	:	337-754-7777
Fax Number	:	337-754-7773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	03/29/2011

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