MEDICARE: DYLAN DUNFORD DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11516	LA

General Provider Information

NPI Number	:	1215620984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN DUNFORD DPT

Provider Business Mailing Address
First Line	:	607 BELLE TERRE BLVD STE B
Second Line	:
City	:	LA PLACE
State	:	LA
Zip	:	70068-1736
Country	:	US
Telephone Number	:	985-359-5483
Fax Number	:	985-359-5484

Provider Business Practice Location Address
First Line	:	607 BELLE TERRE BLVD STE B
Second Line	:
City	:	LA PLACE
State	:	LA
Zip	:	70068-1736
Country	:	US
Telephone Number	:	985-359-5483
Fax Number	:	985-359-5484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2023
Last Update Date	:	05/30/2023

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