Healthcare Provider Details

I. General information

NPI: 1265359426
Provider Name (Legal Business Name): JACK CABALLERO LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD STE 1000
BATON ROUGE LA
70810-7827
US

IV. Provider business mailing address

15154 PROCHE LN
PRIDE LA
70770-9670
US

V. Phone/Fax

Practice location:
  • Phone: 225-938-0043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number329219
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: