Healthcare Provider Details

I. General information

NPI: 1083088520
Provider Name (Legal Business Name): BMMG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6030 LINE AVE
SHREVEPORT LA
71106-2062
US

IV. Provider business mailing address

816 BENTON RD
BOSSIER CITY LA
71111-3744
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-3408
  • Fax:
Mailing address:
  • Phone: 318-747-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number08831R
License Number StateTX

VIII. Authorized Official

Name: MR. MATTHEW FRANZ ST. AMANT
Title or Position: MEMBER
Credential:
Phone: 318-742-3408