Provider Demographics
NPI:1457313827
Name:KAILO LTAC HOSPITAL, LLC
Entity Type:Organization
Organization Name:KAILO LTAC HOSPITAL, LLC
Other - Org Name:CROWLEY REHAB HOSPITAL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/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 1:713 N AVENUE L
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-3832
Mailing Address - Country:US
Mailing Address - Phone:337-783-2859
Mailing Address - Fax:337-783-2891
Practice Address - Street 1:713 N AVENUE L
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-3832
Practice Address - Country:US
Practice Address - Phone:337-783-2859
Practice Address - Fax:337-783-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA532261QM0801X, 284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1703109Medicaid
LA1703109Medicaid