Provider Demographics
NPI:1871166918
Name:BODE, JOHN REES (LMT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:REES
Last Name:BODE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MELBRY RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7946
Mailing Address - Country:US
Mailing Address - Phone:337-371-0871
Mailing Address - Fax:
Practice Address - Street 1:1901 CHEMIN METAIRIE PKWY STE 2
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5660
Practice Address - Country:US
Practice Address - Phone:337-451-4817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134991225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty