Basic Information
| Provider Information | |||||||||
| NPI: | 1689011280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN REGIONAL MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | LEONARD J. CHABERT MEDICAL CENTER PSYCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8166 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703603404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858734141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1978 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858731282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | PEOPLES | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9858734620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN REGIONAL MEDICAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 1705136 | 05 | LA | MEDICAID |