Healthcare Provider Details

I. General information

NPI: 1619324886
Provider Name (Legal Business Name): PRIME EXERCISE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W CONGRESS ST
LAFAYETTE LA
70506-5548
US

IV. Provider business mailing address

2425 W CONGRESS ST
LAFAYETTE LA
70506-5548
US

V. Phone/Fax

Practice location:
  • Phone: 337-371-9312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN CHARLES ROY
Title or Position: EXERCISE THERAPIST/ OWNER
Credential:
Phone: 337-371-9312