Provider Demographics
NPI:1417179748
Name:LAKE AREA REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:LAKE AREA REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:337-477-9292
Mailing Address - Street 1:1909 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4132
Mailing Address - Country:US
Mailing Address - Phone:337-477-9292
Mailing Address - Fax:337-477-9268
Practice Address - Street 1:1909 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4132
Practice Address - Country:US
Practice Address - Phone:337-477-9292
Practice Address - Fax:337-477-9268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C509Medicare PIN