Provider Demographics
NPI:1861572794
Name:SOUTHERN REHAB & MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN REHAB & MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-456-6844
Mailing Address - Street 1:2207 CALIFORNIA DR
Mailing Address - Street 2:STE. 9A
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3571
Mailing Address - Country:US
Mailing Address - Phone:318-747-6118
Mailing Address - Fax:
Practice Address - Street 1:2207 CALIFORNIA DR
Practice Address - Street 2:STE. 9A
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3571
Practice Address - Country:US
Practice Address - Phone:318-747-6118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF7457OtherBLUE CROSS
LA1431478Medicaid
LA1431478Medicaid