Healthcare Provider Details

I. General information

NPI: 1063718138
Provider Name (Legal Business Name): STEWART B. FRESH, DC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 STARBRUSH CIR SUITE 201
COVINGTON LA
70433-7246
US

IV. Provider business mailing address

9 STARBRUSH CIR SUITE 201
COVINGTON LA
70433-7246
US

V. Phone/Fax

Practice location:
  • Phone: 985-259-7774
  • Fax: 985-259-7775
Mailing address:
  • Phone: 985-259-7774
  • Fax: 985-259-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1405
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEWART B FRESH
Title or Position: OWNER
Credential: D.C.
Phone: 985-259-7774