Basic Information
| Provider Information | |||||||||
| NPI: | 1568486959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LC REHAB LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REHAB HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5873 POPLAR HALL DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574661553 | ||||||||
| FaxNumber: | 7574558536 | ||||||||
| Practice Location | |||||||||
| Address1: | 5873 POPLAR HALL DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574661553 | ||||||||
| FaxNumber: | 7574558536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOKE | ||||||||
| AuthorizedOfficialFirstName: | MAURY | ||||||||
| AuthorizedOfficialMiddleName: | WISE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7574661553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | ATS CRTS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 186532 | 01 | VA | ANTHEM | OTHER | 99886 | 01 | OPTIMA | OTHER | 186517 | 01 | VA | ANTHEM | OTHER | 010207720 | 05 | VA | MEDICAID | 010199816 | 05 | VA | MEDICAID |