Provider Demographics
NPI:1073826681
Name:PROVISION REHAB, LLC
Entity Type:Organization
Organization Name:PROVISION REHAB, LLC
Other - Org Name:PROVISION REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEADRIAN
Authorized Official - Middle Name:ANDRELL
Authorized Official - Last Name:ALEXANDER-FICKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-238-4030
Mailing Address - Street 1:113 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5039
Mailing Address - Country:US
Mailing Address - Phone:318-542-9367
Mailing Address - Fax:
Practice Address - Street 1:113 SOUTH DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5039
Practice Address - Country:US
Practice Address - Phone:318-238-4030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health