Healthcare Provider Details

I. General information

NPI: 1073818399
Provider Name (Legal Business Name): PREMIER REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 PAUL MAILLARD RD
LULING LA
70070-4351
US

IV. Provider business mailing address

211 E WORTHY ST BUILDING 4
GONZALES LA
70737-4232
US

V. Phone/Fax

Practice location:
  • Phone: 985-785-8271
  • Fax: 985-785-9944
Mailing address:
  • Phone: 225-644-7044
  • Fax: 225-644-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1841
License Number StateLA

VIII. Authorized Official

Name: BRIDGET REDMOND
Title or Position: CEO
Credential:
Phone: 225-644-7044