Provider Demographics
NPI:1215708599
Name:PREMIER PERFORMANCE PHYSICAL THERAPY
Entity type:Organization
Organization Name:PREMIER PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:337-202-7045
Mailing Address - Street 1:19503 LAKE CHARLES HWY
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2313
Mailing Address - Country:US
Mailing Address - Phone:337-202-7045
Mailing Address - Fax:
Practice Address - Street 1:103 W GIBSON ST STE 102
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4974
Practice Address - Country:US
Practice Address - Phone:337-202-7045
Practice Address - Fax:337-202-7047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty