=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124232889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORE PHYSICAL THERAPY ,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 FORSYTHE BYP STE B
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-2168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-325-3930
-----------------------------------------------------
Fax | 318-325-3981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 FORSYTHE BYP STE B
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-2168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-325-3930
-----------------------------------------------------
Fax | 318-325-3981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MR. ROBERT BARRY DOPSON
-----------------------------------------------------
Credential | RRT
-----------------------------------------------------
Telephone | 31832533930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------