Provider Demographics
NPI:1548659840
Name:CORE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:CORE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-336-5400
Mailing Address - Street 1:4616 HIGHWAY 84 W
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3357
Mailing Address - Country:US
Mailing Address - Phone:318-336-5400
Mailing Address - Fax:318-336-8621
Practice Address - Street 1:4616 HIGHWAY 84 W
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373
Practice Address - Country:US
Practice Address - Phone:318-336-5400
Practice Address - Fax:318-336-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09009R261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05702398Medicaid
LA236280Medicaid