Provider Demographics
NPI:1528120011
Name:BORDELON, GARY NEIL (LPT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:NEIL
Last Name:BORDELON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:235 CANAL STREET
Mailing Address - City:ARNAUDVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70512
Mailing Address - Country:US
Mailing Address - Phone:337-754-7777
Mailing Address - Fax:337-754-7773
Practice Address - Street 1:235 CANAL STREET
Practice Address - Street 2:
Practice Address - City:ARNAUDVILLE
Practice Address - State:LA
Practice Address - Zip Code:70512
Practice Address - Country:US
Practice Address - Phone:337-754-7777
Practice Address - Fax:337-754-7773
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAPT 01633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B357C658Medicare PIN