Healthcare Provider Details

I. General information

NPI: 1407890130
Provider Name (Legal Business Name): LISA COX REARDON M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 NORTH CASTLEMAN STREET
OAK GROVE LA
71263-0788
US

IV. Provider business mailing address

PO BOX 761 1627 SKINNER LANE
OAK GROVE LA
71263-0761
US

V. Phone/Fax

Practice location:
  • Phone: 318-428-3249
  • Fax: 318-428-7547
Mailing address:
  • Phone: 318-428-3249
  • Fax: 318-428-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number1183
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: