Healthcare Provider Details

I. General information

NPI: 1538723564
Provider Name (Legal Business Name): DWAYNE PATRICK BONVILLAIN DPT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36491 DUTCHTOWN GARDENS AVE
GEISMAR LA
70734-3081
US

IV. Provider business mailing address

6756 LANGLEY DR
BATON ROUGE LA
70809-5178
US

V. Phone/Fax

Practice location:
  • Phone: 225-744-7325
  • Fax: 225-744-7330
Mailing address:
  • Phone: 225-744-7325
  • Fax: 225-744-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12343R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT4504
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT4504
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: