=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518929926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL REHABILITATION HOSPITAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 FRONT ST
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71373-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-336-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1499
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39043-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-824-9010
-----------------------------------------------------
Fax | 601-824-9044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | SONJA SHARP WATKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-824-9010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273Y00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282E00000X
-----------------------------------------------------
Taxonomy Name | Long Term Care Hospital
-----------------------------------------------------
License Number | 518
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 275N00000X
-----------------------------------------------------
Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 282E00000X
-----------------------------------------------------
Taxonomy Name | Long Term Care Hospital
-----------------------------------------------------
License Number | 654
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------