Healthcare Provider Details

I. General information

NPI: 1699012633
Provider Name (Legal Business Name): BLAKE MATTHEW CARRIERE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 HARDING ST
LAFAYETTE LA
70503-2320
US

IV. Provider business mailing address

PO BOX 52396
LAFAYETTE LA
70505-2396
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-3111
  • Fax: 337-232-5400
Mailing address:
  • Phone: 337-232-3111
  • Fax: 337-232-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number08336
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: