MEDICARE: AGAPE COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225279656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY, INC.

Provider Business Mailing Address
First Line	:	2835 HOLLYWOOD AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-3848
Country	:	US
Telephone Number	:	318-631-4181
Fax Number	:	318-525-0422

Provider Business Practice Location Address
First Line	:	2835 HOLLYWOOD AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-3848
Country	:	US
Telephone Number	:	318-631-4181
Fax Number	:	318-525-0422

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KEITH ROBINSON
Credential	:
Telephone Number	:	318-572-0795

Provider Enumeration Date	:	03/15/2009
Last Update Date	:	03/15/2009

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