Provider Demographics
NPI:1639866353
Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Entity Type:Organization
Organization Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Other - Org Name:RIVERBRIDGE PULMONARY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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 1:209 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL REHABILITATION HOSPITAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-21
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty