Provider Demographics
NPI:1972696169
Name:CAVALLINO, MARC D (MPT, OCS)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:D
Last Name:CAVALLINO
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 RIVER OAKS RD W
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-2163
Mailing Address - Country:US
Mailing Address - Phone:504-733-2111
Mailing Address - Fax:504-733-5999
Practice Address - Street 1:1516 RIVER OAKS RD W
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-2163
Practice Address - Country:US
Practice Address - Phone:504-733-2111
Practice Address - Fax:504-733-5999
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C087Medicare ID - Type UnspecifiedPROVIDER NUMBER