Provider Demographics
NPI:1720217755
Name:PATHWAY REHABILITATION HOSPITAL OF BOSSIER, LLC
Entity Type:Organization
Organization Name:PATHWAY REHABILITATION HOSPITAL OF BOSSIER, LLC
Other - Org Name:PATHWAY REHABILITATION HOSPITAL OF BOSSIER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:EZEKIEL
Authorized Official - Last Name:MCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:318-841-2585
Mailing Address - Street 1:4900 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4521
Mailing Address - Country:US
Mailing Address - Phone:318-841-5555
Mailing Address - Fax:318-841-5563
Practice Address - Street 1:4900 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4521
Practice Address - Country:US
Practice Address - Phone:318-841-5555
Practice Address - Fax:318-841-5563
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAY HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-12
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA685283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2700006Medicaid
LA193094Medicare Oscar/Certification