1851688105 NPI number — MIND REHABILITATION AND RESOURCE CENTER, INC

Table of content: (NPI 1851688105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851688105 NPI number — MIND REHABILITATION AND RESOURCE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND REHABILITATION AND RESOURCE CENTER, INC
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:
1851688105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6009 FINANCIAL PLZ STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71129-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-828-1455
Provider Business Mailing Address Fax Number:
318-828-1626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6009 FINANCIAL PLZ STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71129-2615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-828-1455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHINWEZE
Authorized Official First Name:
KEN
Authorized Official Middle Name:
AKACHUKWU
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
713-553-5863

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1154547578 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194941518 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1427274851 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194941526 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245456664 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629294053 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1447474135 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1841414489 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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