Healthcare Provider Details

I. General information

NPI: 1578517728
Provider Name (Legal Business Name): SOUTHERN LOUISIANA REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310A YOUNGSVILLE HWY
LAFAYETTE LA
70508-4524
US

IV. Provider business mailing address

PO BOX 73701
METAIRIE LA
70033-3701
US

V. Phone/Fax

Practice location:
  • Phone: 337-837-3615
  • Fax: 337-839-8092
Mailing address:
  • Phone: 504-888-1336
  • Fax: 504-888-3362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: JOSEPH BOZZELLE
Title or Position: DIRECTOR
Credential: MD
Phone: 337-837-3615