Basic Information
| Provider Information | |||||||||
| NPI: | 1154549285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHABILITATION SERVICES OF BATON ROUGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 YOUREE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711043600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186750804 | ||||||||
| FaxNumber: | 3184259030 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 WOODDALE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708057567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252141617 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BALISTRELLA | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 3186750804 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1143731 | 05 | LA | MEDICAID |