Healthcare Provider Details

I. General information

NPI: 1588877567
Provider Name (Legal Business Name): UNIVERSAL REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 FERRAND ST STE 2
MONROE LA
71201-3255
US

IV. Provider business mailing address

2414 FERRAND ST STE 2
MONROE LA
71201-3255
US

V. Phone/Fax

Practice location:
  • Phone: 318-342-9979
  • Fax: 318-325-0070
Mailing address:
  • Phone: 318-342-9979
  • Fax: 318-325-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberADC 10106
License Number StateLA

VIII. Authorized Official

Name: MRS. TIFFANY RENE' WYATT
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: MBA
Phone: 318-342-9979