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NPI Code Detail

MEDICARE: MR. BAXTER OLIVER DEAL III MPT, LOTR

MEDICARE: MR. BAXTER OLIVER DEAL III MPT, LOTR
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
1225100000XPhysical Therapist05284LA
2225X00000XOccupational TherapistOTT.Z12349LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1679689566
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BAXTER OLIVER DEAL III MPT, LOTR
Provider Business Mailing Address
First Line : 2002 JOHNSON ST
Second Line : STE 100
City : JENNINGS
State : LA
Zip : 70546-3640
Country : US
Telephone Number : 337-824-4547
Fax Number : 337-824-4548
Provider Business Practice Location Address
First Line : 2002 JOHNSON ST
Second Line : SUITE 100
City : JENNINGS
State : LA
Zip : 70546-3646
Country : US
Telephone Number : 337-824-4547
Fax Number : 337-824-4548
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/22/2006
Last Update Date : 07/25/2016

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Directions to “ MR. BAXTER OLIVER DEAL III MPT, LOTR” Practice Location

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