MEDICARE: PROF. VINCENT MANCUSO 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	PT00163R	LA

General Provider Information

NPI Number	:	1902997877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. VINCENT MANCUSO PT

Provider Business Mailing Address
First Line	:	64519 HIGHWAY 41
Second Line	:	SUITE 7
City	:	PEARL RIVER
State	:	LA
Zip	:	70452-3654
Country	:	US
Telephone Number	:	985-863-7500
Fax Number	:	985-643-2618

Provider Business Practice Location Address
First Line	:	64519 HIGHWAY 41
Second Line	:	SUITE 7
City	:	PEARL RIVER
State	:	LA
Zip	:	70452-3654
Country	:	US
Telephone Number	:	985-863-7500
Fax Number	:	985-643-2618

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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