Provider Demographics
NPI:1255388146
Name:SOUTHERN REHAB & MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN REHAB & MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-835-6845
Mailing Address - Street 1:PO BOX 7220
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70010-7220
Mailing Address - Country:US
Mailing Address - Phone:504-835-6845
Mailing Address - Fax:504-835-7811
Practice Address - Street 1:3511 RIVER RD
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-4160
Practice Address - Country:US
Practice Address - Phone:504-835-6845
Practice Address - Fax:504-835-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3236908001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1431478Medicaid
LAF7457OtherDME
LA3997570001Medicare NSC
LA3997570002Medicare NSC