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General NPI Number Information
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NPI Number | 1902163157
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Entity Type | Organization
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Legal Business Name | ULTIMATE PERFORMANCE SPORTS AND REHAB LLC
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Dates
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Enumeration Date | 04/12/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 313 ALAMO ST SUITE B
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City | LAKE CHARLES
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State | LA
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Zip | 70601-8528
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Country | US
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Telephone | 337-523-0776
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4610
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City | LAKE CHARLES
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State | LA
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Zip | 70606-4610
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Country | US
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Telephone | 337-312-1446
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Fax | 337-312-1490
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEREMY ROSS WARD
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Credential | DC
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Telephone | 337-523-0776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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