Healthcare Provider Details

I. General information

NPI: 1669900858
Provider Name (Legal Business Name): EDWARD KEVIN MIZELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S TYLER ST
COVINGTON LA
70433-2334
US

IV. Provider business mailing address

1414 S TYLER ST
COVINGTON LA
70433-2334
US

V. Phone/Fax

Practice location:
  • Phone: 985-894-4622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number000616
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: