Provider Demographics
NPI:1649399551
Name:PREMIER MEDICAL REHAB LAPLACE INC
Entity Type:Organization
Organization Name:PREMIER MEDICAL REHAB LAPLACE INC
Other - Org Name:NEW BACK MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLOUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-653-8903
Mailing Address - Street 1:900 W AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3816
Mailing Address - Country:US
Mailing Address - Phone:985-652-8100
Mailing Address - Fax:985-652-8411
Practice Address - Street 1:900 W AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3816
Practice Address - Country:US
Practice Address - Phone:985-652-8100
Practice Address - Fax:985-652-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA415111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1941409Medicaid
LAT19938Medicare UPIN
LA57928Medicare ID - Type Unspecified
LA1941409Medicaid