Provider Demographics
NPI:1518929926
Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Entity type:Organization
Organization Name:PROFESSIONAL REHABILITATION HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:SHARP
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-824-9010
Mailing Address - Street 1:PO BOX 1499
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1499
Mailing Address - Country:US
Mailing Address - Phone:601-824-9010
Mailing Address - Fax:601-824-9044
Practice Address - Street 1:209 FRONT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2837
Practice Address - Country:US
Practice Address - Phone:318-336-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
273Y00000X, 275N00000X
LA518282E00000X
LA654282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No273Y00000XHospital UnitsRehabilitation Unit
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1764914Medicaid
LA60973OtherBLUE CROSS PROVIDER #
LA192028Medicare Oscar/Certification