MEDICARE: JESSE L WIED PT PHYSICAL THERAPY CLINIC INC

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

General Provider Information

NPI Number	:	1538101902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSE L WIED PT PHYSICAL THERAPY CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 14151
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71207-4151
Country	:	US
Telephone Number	:	318-322-7050
Fax Number	:	318-322-7031

Provider Business Practice Location Address
First Line	:	1901 ROSELAWN AVE SUITE A
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201
Country	:	US
Telephone Number	:	318-322-7050
Fax Number	:	318-322-7031

Authorized Official
Title or Position	:	SECRETARY TREASURER
Name	:	MRS. LAURA CAGE WIED
Credential	:
Telephone Number	:	318-322-7050

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	07/29/2015

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