Basic Information
| Provider Information | |||||||||
| NPI: | 1154956241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHREVEPORT REHABILITATION HOSPITAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CENTURY PKWY STE 320 | ||||||||
| Address2: | |||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750138136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696406503 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1451 FERN CIRCLE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711057501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696406503 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2020 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | NIXON | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4696406503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | Y | Hospitals | Rehabilitation Hospital |
No ID Information.