Basic Information
| Provider Information | |||||||||
| NPI: | 1669689634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSOUTH REHABILITATION CENTER,INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015513 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184101062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | EUBANKS | ||||||||
| AuthorizedOfficialFirstName: | SAUNDRA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3184101062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1565563 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1565563 | 05 | LA | MEDICAID |