Healthcare Provider Details

I. General information

NPI: 1356478119
Provider Name (Legal Business Name): BROUSSARD PHYSICAL THERAPY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 HIGHLAND DR
MANY LA
71449-3717
US

IV. Provider business mailing address

295 HIGHLAND DR
MANY LA
71449-3717
US

V. Phone/Fax

Practice location:
  • Phone: 318-256-6285
  • Fax: 318-256-6658
Mailing address:
  • Phone: 318-256-6285
  • Fax: 318-256-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT00257
License Number StateLA

VIII. Authorized Official

Name: MR. JAMES KEITH BROUSSARD
Title or Position: PHYSICAL THERAPIST
Credential: P.T.
Phone: 318-256-6285