Basic Information
| Provider Information | |||||||||
| NPI: | 1952767618 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIND REHABILITATION AND RESOURCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 LINE AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
| FaxNumber: | 3188281626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 LINE AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
| FaxNumber: | 3188281626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHINWEZE | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3188281455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2154869 | 05 | LA | MEDICAID |