Healthcare Provider Details

I. General information

NPI: 1255912663
Provider Name (Legal Business Name): JUSTIN THOMAS LOFTON PTA, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 STARING LN
BATON ROUGE LA
70810-4064
US

IV. Provider business mailing address

215 STARING LN
BATON ROUGE LA
70810-4064
US

V. Phone/Fax

Practice location:
  • Phone: 225-416-2733
  • Fax:
Mailing address:
  • Phone: 225-416-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA8143
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA9243
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: