Healthcare Provider Details

I. General information

NPI: 1407825060
Provider Name (Legal Business Name): LINCOLN OUTPATIENT THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 NORTHPOINTE LANE
RUSTON LA
71270-3879
US

IV. Provider business mailing address

PO BOX 1306
RUSTON LA
71273-1306
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-9601
  • Fax: 318-255-7971
Mailing address:
  • Phone: 318-255-9601
  • Fax: 318-255-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateLA

VIII. Authorized Official

Name: MATTHEW RANDOLPH SHIRLEY
Title or Position: PRESIDENT
Credential: PT
Phone: 318-255-9601