Provider Demographics
NPI:1154910024
Name:ALPHONSO, LUKE
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:ALPHONSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 PORT ARTHUR TER
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4600
Mailing Address - Country:US
Mailing Address - Phone:337-377-0477
Mailing Address - Fax:337-239-1062
Practice Address - Street 1:1108 PORT ARTHUR TER
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4600
Practice Address - Country:US
Practice Address - Phone:337-377-0477
Practice Address - Fax:337-239-1062
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAMT6960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty