Provider Demographics
NPI:1427137074
Name:REHABILITATION SERVICES OF NORTHWEST LOUISIANA, LLC
Entity type:Organization
Organization Name:REHABILITATION SERVICES OF NORTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. AMANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-675-0804
Mailing Address - Street 1:1000 CHINABERRY DR STE 900
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:318-746-0420
Mailing Address - Fax:318-626-5429
Practice Address - Street 1:1301 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-5117
Practice Address - Country:US
Practice Address - Phone:318-675-0804
Practice Address - Fax:318-425-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
LA1151254261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health