Provider Demographics
NPI:1851688105
Name:MIND REHABILITATION AND RESOURCE CENTER, INC
Entity Type:Organization
Organization Name:MIND REHABILITATION AND RESOURCE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:AKACHUKWU
Authorized Official - Last Name:CHINWEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-553-5863
Mailing Address - Street 1:6009 FINANCIAL PLZ STE 102
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2615
Mailing Address - Country:US
Mailing Address - Phone:318-828-1455
Mailing Address - Fax:318-828-1626
Practice Address - Street 1:6009 FINANCIAL PLZ STE 102
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2615
Practice Address - Country:US
Practice Address - Phone:318-828-1455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1154547578Medicaid
LA1194941518Medicaid
LA1427274851Medicaid
LA1194941526Medicaid
LA1245456664Medicaid
LA1629294053Medicaid
LA1447474135Medicaid
LA1841414489Medicaid