Provider Demographics
NPI:1356493530
Name:SPECTRUM REHAB SERVICES, INC.
Entity Type:Organization
Organization Name:SPECTRUM REHAB SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-746-0420
Mailing Address - Street 1:30826 LINDER RD
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-8507
Mailing Address - Country:US
Mailing Address - Phone:225-665-7878
Mailing Address - Fax:225-665-7856
Practice Address - Street 1:30826 LINDER RD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-8507
Practice Address - Country:US
Practice Address - Phone:225-665-7878
Practice Address - Fax:225-665-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1548839251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1989151Medicaid
LA1548839Medicaid