Healthcare Provider Details

I. General information

NPI: 1902163157
Provider Name (Legal Business Name): ULTIMATE PERFORMANCE SPORTS AND REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 ALAMO ST SUITE B
LAKE CHARLES LA
70601-8528
US

IV. Provider business mailing address

PO BOX 4610
LAKE CHARLES LA
70606-4610
US

V. Phone/Fax

Practice location:
  • Phone: 337-523-0776
  • Fax:
Mailing address:
  • Phone: 337-312-1446
  • Fax: 337-312-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY ROSS WARD
Title or Position: OWNER
Credential: DC
Phone: 337-523-0776