=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508207705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD SUMMERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2013
-----------------------------------------------------
Last Update Date | 07/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 MCCLENDON CHURCH RD
-----------------------------------------------------
City | WEST MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71292-8052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-410-8376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4109 HIGHWAY 98 W
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39666-9132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A8536R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------