Healthcare Provider Details

I. General information

NPI: 1134202930
Provider Name (Legal Business Name): KEITH A FOGLE PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 SHADOWS LN
BATON ROUGE LA
70806-6530
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-927-9185
  • Fax: 225-231-3818
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number06970
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number06970
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: