Provider Demographics
NPI:1356478119
Name:BROUSSARD PHYSICAL THERAPY CLINIC, INC.
Entity type:Organization
Organization Name:BROUSSARD PHYSICAL THERAPY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:318-256-6285
Mailing Address - Street 1:295 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-3717
Mailing Address - Country:US
Mailing Address - Phone:318-256-6285
Mailing Address - Fax:318-256-6658
Practice Address - Street 1:295 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3717
Practice Address - Country:US
Practice Address - Phone:318-256-6285
Practice Address - Fax:318-256-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT00257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8882891OtherCIGNA I.D. #
LA7568170OtherAETNA I.D. #
LA4C335Medicare ID - Type Unspecified