Healthcare Provider Details

I. General information

NPI: 1700973054
Provider Name (Legal Business Name): LIFESPAN PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 HWY 56
CHAUVIN LA
70344
US

IV. Provider business mailing address

PO BOX 58
CHAUVIN LA
70344-0058
US

V. Phone/Fax

Practice location:
  • Phone: 985-594-8332
  • Fax: 985-594-8389
Mailing address:
  • Phone: 985-594-8332
  • Fax: 985-594-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. IME E UDOM
Title or Position: CLINICAL DIRECTOR
Credential: PT, DPT, PHD
Phone: 985-594-8332