Healthcare Provider Details

I. General information

NPI: 1548860539
Provider Name (Legal Business Name): DERRICK HOTARD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 MAIN ST
ZACHARY LA
70791-3943
US

IV. Provider business mailing address

4135 BERTHELOT ST
ADDIS LA
70710-2648
US

V. Phone/Fax

Practice location:
  • Phone: 225-286-0181
  • Fax:
Mailing address:
  • Phone: 225-252-4720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number10689
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: