Provider Demographics
NPI:1700876414
Name:CLINTON REHABILITATION HOSPITAL, LLC
Entity Type:Organization
Organization Name:CLINTON REHABILITATION HOSPITAL, LLC
Other - Org Name:GULF STATES LTAC OF FELICIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND COO
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-216-2299
Mailing Address - Street 1:9725 GRACE LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-4925
Mailing Address - Country:US
Mailing Address - Phone:225-683-1600
Mailing Address - Fax:225-683-1616
Practice Address - Street 1:9725 GRACE LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-4925
Practice Address - Country:US
Practice Address - Phone:225-683-1600
Practice Address - Fax:225-683-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA462282E00000X, 284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1702013Medicaid
LA1702013Medicaid