Healthcare Provider Details

I. General information

NPI: 1134204167
Provider Name (Legal Business Name): FLEUR DE LIS PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 SPAIN ST
NEW ORLEANS LA
70117-7824
US

IV. Provider business mailing address

839 SPAIN ST
NEW ORLEANS LA
70117-7824
US

V. Phone/Fax

Practice location:
  • Phone: 504-943-8026
  • Fax:
Mailing address:
  • Phone: 504-943-8026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberNONE
License Number StateLA

VIII. Authorized Official

Name: MARK WILBURN MOORE
Title or Position: PHYSICAL THERAPIST
Credential: MPT
Phone: 504-943-8026