Healthcare Provider Details

I. General information

NPI: 1669427977
Provider Name (Legal Business Name): BANYON L TUMINELLO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14159 HIGHWAY 16
AMITE LA
70422-4603
US

IV. Provider business mailing address

PO BOX 971
AMITE LA
70422-0971
US

V. Phone/Fax

Practice location:
  • Phone: 985-747-3422
  • Fax: 985-747-3424
Mailing address:
  • Phone: 985-747-3422
  • Fax: 985-747-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02691
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: