Healthcare Provider Details

I. General information

NPI: 1427084920
Provider Name (Legal Business Name): SUPERIOR REHABILITATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WHISPERWOOD BLVD
SLIDELL LA
70458-1136
US

IV. Provider business mailing address

85 WHISPERWOOD BLVD
SLIDELL LA
70458-1136
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-2866
  • Fax: 985-781-5395
Mailing address:
  • Phone: 985-641-2866
  • Fax: 985-781-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number04523
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1134228
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name: MR. GARY JOSEPH DRAGON JR.
Title or Position: PT, DPT/OWNER
Credential: PT
Phone: 985-641-2866