Provider Demographics
NPI:1023014131
Name:CENTURY 2 THERAPY DIVISION STREET CENTER, LLC
Entity Type:Organization
Organization Name:CENTURY 2 THERAPY DIVISION STREET CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LELAND
Authorized Official - Last Name:GUIDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-293-4000
Mailing Address - Street 1:3901 HOUMA BLVD
Mailing Address - Street 2:STE 113
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2930
Mailing Address - Country:US
Mailing Address - Phone:504-888-1330
Mailing Address - Fax:504-888-6201
Practice Address - Street 1:3901 HOUMA BLVD
Practice Address - Street 2:STE 113
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2930
Practice Address - Country:US
Practice Address - Phone:504-888-1330
Practice Address - Fax:504-888-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7307358OtherAETNA PROVIDER NUMBER
LA1113671Medicaid
LA7307358OtherAETNA PROVIDER NUMBER