=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336716844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THIBODAUX PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 E BAYOU RD STE C
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-446-3736
-----------------------------------------------------
Fax | 985-446-3701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 E BAYOU RD STE C
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-446-3736
-----------------------------------------------------
Fax | 985-446-3701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. CRAIG S PATE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 985-446-3736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------