Provider Demographics
NPI:1578517728
Name:SOUTHERN LOUISIANA REHAB LLC
Entity Type:Organization
Organization Name:SOUTHERN LOUISIANA REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOZZELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-837-3615
Mailing Address - Street 1:PO BOX 73701
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70033-3701
Mailing Address - Country:US
Mailing Address - Phone:504-888-1336
Mailing Address - Fax:504-888-3362
Practice Address - Street 1:310A YOUNGSVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4524
Practice Address - Country:US
Practice Address - Phone:337-837-3615
Practice Address - Fax:337-839-8092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADC2473OtherMEDICARE RAILROAD
LA5CK93Medicare ID - Type Unspecified
LAH78125Medicare UPIN