Basic Information
| Provider Information | |||||||||
| NPI: | 1215161922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LCMS REHABILITATION INSTITUTE OF SOUTHWEST LOUISIANA | ||||||||
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| OtherOrganizationName: | MMG/MOSS CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122108 DEPT 2108 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WALTERS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374808066 | ||||||||
| FaxNumber: | 3374808109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HATCHER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3374942094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE CHARLES MEDICAL SERVICES, INC. | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 2084A0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 09-00013263 | 01 | LA | OCCUPATIONAL LICENSE | OTHER | 2353993 | 05 | LA | MEDICAID |