Provider Demographics
NPI:1144640442
Name:SOUTHERN REHAB PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SOUTHERN REHAB PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/ AGENT / PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:504-628-8085
Mailing Address - Street 1:900 WOODLAND HWY
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 WOODLAND HWY
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-1633
Practice Address - Country:US
Practice Address - Phone:504-628-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08652261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy