Provider Demographics
NPI:1730485749
Name:LOUISE GRAHAM REGENERATION CENTER
Entity Type:Organization
Organization Name:LOUISE GRAHAM REGENERATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-578-5437
Mailing Address - Street 1:2301 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-1646
Mailing Address - Country:US
Mailing Address - Phone:727-327-9444
Mailing Address - Fax:727-327-9649
Practice Address - Street 1:2301 3RD AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-1646
Practice Address - Country:US
Practice Address - Phone:727-327-9444
Practice Address - Fax:727-327-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024019201Medicaid
FL024019296Medicaid