Provider Demographics
NPI:1972142024
Name:RESILIENCE CONCIERGE PHYSICAL THERAPY
Entity type:Organization
Organization Name:RESILIENCE CONCIERGE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:318-471-3306
Mailing Address - Street 1:609 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3815
Mailing Address - Country:US
Mailing Address - Phone:318-471-3306
Mailing Address - Fax:
Practice Address - Street 1:609 WOODMERE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3815
Practice Address - Country:US
Practice Address - Phone:318-471-3306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy