Basic Information
| Provider Information | |||||||||
| NPI: | 1205988607 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | L C REHAB LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHAB HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5873 POPLAR HALL DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574661553 | ||||||||
| FaxNumber: | 7574558536 | ||||||||
| Practice Location | |||||||||
| Address1: | 2135 STAPLES MILL RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232302905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043537244 | ||||||||
| FaxNumber: | 8043535976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | COOKE | ||||||||
| AuthorizedOfficialFirstName: | MAURY | ||||||||
| AuthorizedOfficialMiddleName: | WISE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7574661553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 043016L14460 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 7704399 | 05 | NC | MEDICAID | 010207720 | 05 | VA | MEDICAID | 186532 | 01 | VA | ANTHEM | OTHER |