MEDICARE: KERRY WOODS PT

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	03301F	LA

General Provider Information

NPI Number	:	1861639387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY WOODS PT

Provider Business Mailing Address
First Line	:	4080 NELSON RD STE 400
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2439
Country	:	US
Telephone Number	:	337-497-0434
Fax Number	:	337-497-0469

Provider Business Practice Location Address
First Line	:	4080 NELSON RD STE 400
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2439
Country	:	US
Telephone Number	:	337-497-0434
Fax Number	:	337-497-0469

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2009
Last Update Date	:	01/21/2009

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