MEDICARE: THE FASCIA PERFORMANCE GROUP, 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1336959766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FASCIA PERFORMANCE GROUP, LLC

Provider Business Mailing Address
First Line	:	1600 SAINT CHARLES AVE # 102
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4436
Country	:	US
Telephone Number	:	504-386-3488
Fax Number	:	800-471-1536

Provider Business Practice Location Address
First Line	:	1600 SAINT CHARLES AVE # 1B
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4436
Country	:	US
Telephone Number	:	504-704-1254
Fax Number	:	866-572-0930

Authorized Official
Title or Position	:	CEO
Name	:	JACQUES COURSEAULT
Credential	:	MD
Telephone Number	:	504-386-3488

Provider Enumeration Date	:	01/08/2025
Last Update Date	:	04/06/2026

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