Provider Demographics
NPI:1710321716
Name:PREMIER REHAB OF SOUTHWEST LOUISIANA LLC
Entity Type:Organization
Organization Name:PREMIER REHAB OF SOUTHWEST LOUISIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-542-9367
Mailing Address - Street 1:PO BOX 13958
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-3958
Mailing Address - Country:US
Mailing Address - Phone:318-542-9367
Mailing Address - Fax:
Practice Address - Street 1:840 W BAYOU PINES DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7495
Practice Address - Country:US
Practice Address - Phone:318-542-9367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-20
Last Update Date:2013-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health