Provider Demographics
NPI:1407825060
Name:LINCOLN OUTPATIENT THERAPY SERVICES
Entity Type:Organization
Organization Name:LINCOLN OUTPATIENT THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:318-255-9601
Mailing Address - Street 1:PO BOX 1306
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1306
Mailing Address - Country:US
Mailing Address - Phone:318-255-9601
Mailing Address - Fax:318-255-7971
Practice Address - Street 1:1817 NORTHPOINTE LANE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3879
Practice Address - Country:US
Practice Address - Phone:318-255-9601
Practice Address - Fax:318-255-7971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7822443OtherAETNA
AL1169234Medicaid
AL1169234Medicaid