=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154790327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOGALUSA REHABILITATION HOSPITAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2015
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 S. COLUMBIA STREET
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70427-4721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-254-4535
-----------------------------------------------------
Fax | 337-269-5506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 S. COLUMBIA STREET
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70427-4721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-254-4535
-----------------------------------------------------
Fax | 337-269-5506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MANAGER
-----------------------------------------------------
Name | CHARLES MATTHEWS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-254-4535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283X00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------