Provider Demographics
NPI:1932196300
Name:LEESVILLE REHABILITATION HOSPITAL LLC
Entity Type:Organization
Organization Name:LEESVILLE REHABILITATION HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-392-8118
Mailing Address - Street 1:323 WEST WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-1531
Mailing Address - Country:US
Mailing Address - Phone:318-556-8000
Mailing Address - Fax:318-556-1197
Practice Address - Street 1:900 S 6TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4723
Practice Address - Country:US
Practice Address - Phone:337-392-8118
Practice Address - Fax:337-392-8415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4555283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1702951Medicaid
LA1702951Medicaid