Healthcare Provider Details

I. General information

NPI: 1134412216
Provider Name (Legal Business Name): PHYSIOFIT DME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WHITE ROSE DR
RACELAND LA
70394-2644
US

IV. Provider business mailing address

120 WHITE ROSE DR
RACELAND LA
70394-2644
US

V. Phone/Fax

Practice location:
  • Phone: 985-532-2229
  • Fax: 985-532-2230
Mailing address:
  • Phone: 985-532-2229
  • Fax: 985-532-2230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number6211
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number6211
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6211
License Number StateLA

VIII. Authorized Official

Name: JEREMY JOHN BREAUX
Title or Position: OWNER
Credential: B.S.
Phone: 985-381-3811