MEDICARE: JAMES LACLEDE PT, DPT

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	1335294	TX
2	225100000X	Physical Therapist	CP015157T	AZ

General Provider Information

NPI Number	:	1669083507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES LACLEDE PT, DPT

Provider Business Mailing Address
First Line	:	2756 RICHLANDS HWY
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3611
Country	:	US
Telephone Number	:	252-228-4643
Fax Number	:

Provider Business Practice Location Address
First Line	:	2756 RICHLANDS HWY
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3611
Country	:	US
Telephone Number	:	252-228-4643
Fax Number	:

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

Provider Enumeration Date	:	08/13/2020
Last Update Date	:	03/10/2024

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