Healthcare Provider Details

I. General information

NPI: 1386254530
Provider Name (Legal Business Name): AHMAD MARWAN KASKAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 AIRLINE DR
BOSSIER CITY LA
71111-2058
US

IV. Provider business mailing address

10007 WINDING RIDGE DR
SHREVEPORT LA
71106-7685
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-5440
  • Fax:
Mailing address:
  • Phone: 318-564-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number10544
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: