MEDICARE: DIVERSIFIED REHABILITATION SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	12265	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205018892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED REHABILITATION SERVICE

Provider Business Mailing Address
First Line	:	11760 S HARRELLS FERRY RD
Second Line	:	STE G
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2374
Country	:	US
Telephone Number	:	225-756-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	11760 S HARRELLS FERRY RD
Second Line	:	STE G
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2374
Country	:	US
Telephone Number	:	225-756-2700
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CASSANDRA BATES
Credential	:
Telephone Number	:	225-756-2700

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	12/06/2007

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