Provider Demographics
NPI:1790902948
Name:HOLISTIC EDUCATIONAL REHAB CENTER
Entity Type:Organization
Organization Name:HOLISTIC EDUCATIONAL REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHUN
Authorized Official - Middle Name:DOYLE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1504-915-6596
Mailing Address - Street 1:1799 STUMPF BLVD
Mailing Address - Street 2:BLDG 7 STE 7
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-3950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1799 STUMPF BLVD
Practice Address - Street 2:BLDG 7 STE 7
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-915-6596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12455305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1194883Medicaid