Basic Information
| Provider Information | |||||||||
| NPI: | 1356387146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTUS HEALTH NORTHERN LOUISIANA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHRISTUS INPATIENT REHABILITATION CENTER SHREVEPORT-BOSSIER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843577 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752843577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007567999 | ||||||||
| FaxNumber: | 4692821791 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 MARGARET PL | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186814900 | ||||||||
| FaxNumber: | 3186814427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | TRAWICK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | STEEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3186815054 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 60952 | 01 | LA | BLUE CROSS | OTHER |