MEDICARE: ANACOCO BAYOU PHYSICAL REHAB

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	261QP2000X	Physical Therapy Clinic/Center	01612	LA

General Provider Information

NPI Number	:	1235537168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANACOCO BAYOU PHYSICAL REHAB

Provider Business Mailing Address
First Line	:	154 E LAKE DR
Second Line	:
City	:	ANACOCO
State	:	LA
Zip	:	71403-3158
Country	:	US
Telephone Number	:	337-224-3471
Fax Number	:

Provider Business Practice Location Address
First Line	:	154 E LAKE DR
Second Line	:
City	:	ANACOCO
State	:	LA
Zip	:	71403-3158
Country	:	US
Telephone Number	:	337-224-3471
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. JEFFREY DON WARREN I
Credential	:	BS
Telephone Number	:	337-224-3471

Provider Enumeration Date	:	12/09/2014
Last Update Date	:	12/09/2014

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