MEDICARE: PREMIER REHAB & AQUATICS

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	00211	LA

General Provider Information

NPI Number	:	1356319552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER REHAB & AQUATICS

Provider Business Mailing Address
First Line	:	7015 HWY 190 E SERV RD
Second Line	:	SUITE 103
City	:	COVINGTON
State	:	LA
Zip	:	70433-4960
Country	:	US
Telephone Number	:	985-893-8285
Fax Number	:	985-893-8288

Provider Business Practice Location Address
First Line	:	7015 HWY 190 E SERV RD
Second Line	:	SUITE 103
City	:	COVINGTON
State	:	LA
Zip	:	70433-4960
Country	:	US
Telephone Number	:	985-893-8285
Fax Number	:	985-893-8288

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MARTIN VINCE TASSIN
Credential	:	LPT
Telephone Number	:	985-893-8285

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	11/14/2007

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