Provider Demographics
NPI:1518993112
Name:PRIMARY REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:PRIMARY REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-497-0434
Mailing Address - Street 1:4080 NELSON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2418
Mailing Address - Country:US
Mailing Address - Phone:337-497-0434
Mailing Address - Fax:
Practice Address - Street 1:4080 NELSON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2418
Practice Address - Country:US
Practice Address - Phone:337-497-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548928Medicaid
LA1548928Medicaid