Healthcare Provider Details

I. General information

NPI: 1962338889
Provider Name (Legal Business Name): DAVID BOURQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N RANGE AVE
DENHAM SPRINGS LA
70726-2400
US

IV. Provider business mailing address

1000 N RANGE AVE
DENHAM SPRINGS LA
70726-2400
US

V. Phone/Fax

Practice location:
  • Phone: 225-665-8851
  • Fax:
Mailing address:
  • Phone: 225-665-8851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.J00261
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: