Provider Demographics
NPI:1518929926
Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Entity Type:Organization
Organization Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Other - Org Name:RIVERBRIDGE SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:SHARP
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-824-9010
Mailing Address - Street 1:PO BOX 1499
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1499
Mailing Address - Country:US
Mailing Address - Phone:601-824-9010
Mailing Address - Fax:601-824-9044
Practice Address - Street 1:209 FRONT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2837
Practice Address - Country:US
Practice Address - Phone:318-336-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA518282E00000X
LA654282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA60973OtherBLUE CROSS PROVIDER #
LA1764914Medicaid
LA192028Medicare Oscar/Certification