Basic Information
| Provider Information | |||||||||
| NPI: | 1851688105 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIND REHABILITATION AND RESOURCE CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 LINE AVE STE 338 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1513 LINE AVE | ||||||||
| Address2: | SUITE 338 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHINWEZE | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | AKACHUKWU | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3188281455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1154547578 | 05 | LA | MEDICAID | 1427274851 | 05 | LA | MEDICAID | 1194941526 | 05 | LA | MEDICAID | 1245456664 | 05 | LA | MEDICAID | 1194941518 | 05 | LA | MEDICAID | 1841414489 | 05 | LA | MEDICAID | 1447474135 | 05 | LA | MEDICAID | 1629294053 | 05 | LA | MEDICAID |