Healthcare Provider Details

I. General information

NPI: 1275823320
Provider Name (Legal Business Name): CALCASIEU REHAB AND SPORTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SAM HOUSTON JONES PKWY STE 103
LAKE CHARLES LA
70611-5644
US

IV. Provider business mailing address

2100 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

V. Phone/Fax

Practice location:
  • Phone: 337-217-0997
  • Fax: 337-217-0998
Mailing address:
  • Phone: 337-310-5116
  • Fax: 337-310-5118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number00591
License Number StateLA

VIII. Authorized Official

Name: MR. MICHAEL V MOSS
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 337-217-0997