1255388146 NPI number — SOUTHERN REHAB & MEDICAL CENTER

Table of content: (NPI 1255388146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255388146 NPI number — SOUTHERN REHAB & MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN REHAB & MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255388146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70010-7220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-835-6845
Provider Business Mailing Address Fax Number:
504-835-7811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3511 RIVER RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70121-4160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-835-6845
Provider Business Practice Location Address Fax Number:
504-835-7811
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEACH
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
504-835-6845

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  3236908001 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1431478 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: F7457 . This is a "DME" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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