Healthcare Provider Details

I. General information

NPI: 1679710420
Provider Name (Legal Business Name): MAXX MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 SOUTH DR
NATCHITOCHES LA
71457-5060
US

IV. Provider business mailing address

329 SOUTH DR
NATCHITOCHES LA
71457-5060
US

V. Phone/Fax

Practice location:
  • Phone: 318-238-5900
  • Fax: 318-238-5901
Mailing address:
  • Phone: 318-238-5900
  • Fax: 318-238-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number16920
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number16920
License Number StateLA

VIII. Authorized Official

Name: DR. CHERILYNNE T. COTTLES
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 318-238-5900