Provider Demographics
NPI:1720085962
Name:PHYSICAL THERAPY AND REHABILITATION CENTER,LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND REHABILITATION CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:HAYDEL
Authorized Official - Last Name:TRAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:985-876-7188
Mailing Address - Street 1:225 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2769
Mailing Address - Country:US
Mailing Address - Phone:985-876-7188
Mailing Address - Fax:985-868-8654
Practice Address - Street 1:225 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2769
Practice Address - Country:US
Practice Address - Phone:985-876-7188
Practice Address - Fax:985-868-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT1615225100000X
LAPT166225100000X
LAA3606225200000X
LAZ11353225X00000X
LA4574235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1542563Medicaid
LA196586Medicare ID - Type Unspecified