Provider Demographics
NPI:1316290125
Name:ST. JOHN PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:ST. JOHN PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERWARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:NORSWORTHY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:985-652-9515
Mailing Address - Street 1:1959 HIGHWAY 3125 STE 1
Mailing Address - Street 2:
Mailing Address - City:LUTCHER
Mailing Address - State:LA
Mailing Address - Zip Code:70071-5641
Mailing Address - Country:US
Mailing Address - Phone:225-869-9632
Mailing Address - Fax:225-869-9633
Practice Address - Street 1:1959 HIGHWAY 3125 STE 1
Practice Address - Street 2:
Practice Address - City:LUTCHER
Practice Address - State:LA
Practice Address - Zip Code:70071-5641
Practice Address - Country:US
Practice Address - Phone:225-869-9632
Practice Address - Fax:225-869-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DS10Medicare UPIN