Provider Demographics
NPI:1962424853
Name:SOUTHSHORE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:SOUTHSHORE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:COURET
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:504-885-8969
Mailing Address - Street 1:3515 HESSMER AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4730
Mailing Address - Country:US
Mailing Address - Phone:504-885-8969
Mailing Address - Fax:504-885-9190
Practice Address - Street 1:3515 HESSMER AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4730
Practice Address - Country:US
Practice Address - Phone:504-885-8969
Practice Address - Fax:504-885-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04415261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1689651242Medicare ID - Type UnspecifiedINDIVIDUAL NPI NUMBER
LA4C661Medicare ID - Type UnspecifiedMEDICARE NUMBER