Healthcare Provider Details

I. General information

NPI: 1689707564
Provider Name (Legal Business Name): PHYSIOFIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18641 HWY 3235
GALLIANO LA
70354
US

IV. Provider business mailing address

115 JOHNNY DUFRENE DR
RACELAND LA
70394-2611
US

V. Phone/Fax

Practice location:
  • Phone: 985-475-4555
  • Fax: 985-475-4557
Mailing address:
  • Phone: 985-532-9662
  • Fax: 985-532-3942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5233772
License Number StateLA

VIII. Authorized Official

Name: RUTGERUS FJ JONGBLOETS
Title or Position: OWNER
Credential: PT
Phone: 985-532-9662