Basic Information
| Provider Information | |||||||||
| NPI: | 1366712085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LC 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: | 8667420760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 ALLIED ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229035320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349718808 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | LORRIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTING/OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7578029554 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 43016 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 7704399 | 05 | NC | MEDICAID | 010207720 | 05 | VA | MEDICAID | 653101600 | 05 | MD | MEDICAID |