Provider Demographics
NPI:1578846887
Name:INJURY REHAB CLINIC LLC
Entity Type:Organization
Organization Name:INJURY REHAB CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:RIDGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:504-340-8700
Mailing Address - Street 1:4700 WICHERS DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3041
Mailing Address - Country:US
Mailing Address - Phone:504-340-8700
Mailing Address - Fax:504-340-8701
Practice Address - Street 1:4700 WICHERS DR
Practice Address - Street 2:SUITE 307
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-340-8700
Practice Address - Fax:504-340-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2160907Medicaid