Provider Demographics
NPI:1417946070
Name:ACTIVE REHAB LLC
Entity Type:Organization
Organization Name:ACTIVE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:E PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-788-3600
Mailing Address - Street 1:318 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-2468
Mailing Address - Country:US
Mailing Address - Phone:337-788-3600
Mailing Address - Fax:337-785-1188
Practice Address - Street 1:318 E PARK ST
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2468
Practice Address - Country:US
Practice Address - Phone:337-788-3600
Practice Address - Fax:337-785-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12515261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1110434Medicaid