Provider Demographics
NPI:1699768028
Name:ROY, JOHN R (ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:ROY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 EARLENE DR
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-6331
Mailing Address - Country:US
Mailing Address - Phone:337-332-0836
Mailing Address - Fax:
Practice Address - Street 1:128 E BUTCHER SWITCH RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-3528
Practice Address - Country:US
Practice Address - Phone:337-233-8080
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.J000612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer