1518929926 NPI number — PROFESSIONAL REHABILITATION HOSPITAL LLC

Table of content: (NPI 1518929926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518929926 NPI number — PROFESSIONAL REHABILITATION HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL REHABILITATION HOSPITAL LLC
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:
RIVERBRIDGE SPECIALTY HOSPITAL
Provider Other Organization Name Type Code:
3
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:
1518929926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1499
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39043-1499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-824-9010
Provider Business Mailing Address Fax Number:
601-824-9044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71373-2837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-336-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
SONJA
Authorized Official Middle Name:
SHARP
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
601-824-9010

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , with the licence number:  518 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282E00000X , with the licence number: 654 , 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: 60973 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1764914 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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