Healthcare Provider Details

I. General information

NPI: 1124060264
Provider Name (Legal Business Name): GERARD JOHN BOWEN JR. MHA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2571 HIGHWAY 171
STONEWALL LA
71078-9423
US

IV. Provider business mailing address

6034 BRAEBURN CT
BOSSIER CITY LA
71111-5746
US

V. Phone/Fax

Practice location:
  • Phone: 318-925-6917
  • Fax:
Mailing address:
  • Phone: 318-549-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: