Healthcare Provider Details

I. General information

NPI: 1942904933
Provider Name (Legal Business Name): MIA MANZANARES BAEZA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4027 I 49 S SERVICE RD
OPELOUSAS LA
70570-0757
US

IV. Provider business mailing address

1326 CHURCH ST
ZACHARY LA
70791-2743
US

V. Phone/Fax

Practice location:
  • Phone: 337-948-4212
  • Fax: 337-942-9979
Mailing address:
  • Phone: 225-654-8208
  • Fax: 225-654-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11457
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: