MEDICARE: MS. LISA COX REARDON M.ED

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	376G00000X	Nursing Home Administrator	1183	LA

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	:	1407890130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA COX REARDON M.ED

Provider Business Mailing Address
First Line	:	PO BOX 761
Second Line	:	1627 SKINNER LANE
City	:	OAK GROVE
State	:	LA
Zip	:	71263-0761
Country	:	US
Telephone Number	:	318-428-3249
Fax Number	:	318-428-7547

Provider Business Practice Location Address
First Line	:	307 NORTH CASTLEMAN STREET
Second Line	:
City	:	OAK GROVE
State	:	LA
Zip	:	71263-0788
Country	:	US
Telephone Number	:	318-428-3249
Fax Number	:	318-428-7547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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