Healthcare Provider Details

I. General information

NPI: 1750605622
Provider Name (Legal Business Name): ERIC MARC ERLEWINE MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 FERN AVE
SHREVEPORT LA
71105-4971
US

IV. Provider business mailing address

101 BRADYS RIDGE RD
WELLSBURG WV
26070-1901
US

V. Phone/Fax

Practice location:
  • Phone: 304-670-6965
  • Fax:
Mailing address:
  • Phone: 304-670-6965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number18982
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: