Provider Demographics
NPI:1588877567
Name:UNIVERSAL REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:UNIVERSAL REHABILITATION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:RENE'
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:318-342-9979
Mailing Address - Street 1:2414 FERRAND ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3255
Mailing Address - Country:US
Mailing Address - Phone:318-342-9979
Mailing Address - Fax:318-325-0070
Practice Address - Street 1:2414 FERRAND ST STE 2
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3255
Practice Address - Country:US
Practice Address - Phone:318-342-9979
Practice Address - Fax:318-325-0070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAADC 10106251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health