MEDICARE: MAXX PHYSICAL THERAPY, LLC

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	225X00000X	Occupational Therapist
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1255964110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXX PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	1714 WOLF CIR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2353
Country	:	US
Telephone Number	:	337-508-2505
Fax Number	:

Provider Business Practice Location Address
First Line	:	1714 WOLF CIR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2353
Country	:	US
Telephone Number	:	337-508-2505
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	CHAD ARDOIN
Credential	:	OTR/L
Telephone Number	:	337-508-2505

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	02/19/2020

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