Provider Demographics
NPI:1205988607
Name:L C REHAB LLC
Entity type:Organization
Organization Name:L C REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURY
Authorized Official - Middle Name:WISE
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-466-1553
Mailing Address - Street 1:5873 POPLAR HALL DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3815
Mailing Address - Country:US
Mailing Address - Phone:757-466-1553
Mailing Address - Fax:757-455-8536
Practice Address - Street 1:2135 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2905
Practice Address - Country:US
Practice Address - Phone:804-353-7244
Practice Address - Fax:804-353-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA043016L14460332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704399Medicaid
VA010207720Medicaid
VA186532OtherANTHEM
VA5544020001Medicare ID - Type Unspecified
NC7704399Medicaid