1356442099 NPI number — SOUTHEAST MENTAL HEALTH LLC

Table of content: (NPI 1356442099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356442099 NPI number — SOUTHEAST MENTAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MENTAL HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356442099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 BAYOU RAPIDES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71303-3601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-473-0863
Provider Business Mailing Address Fax Number:
318-473-9889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W MORRIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403-4120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-473-0863
Provider Business Practice Location Address Fax Number:
318-473-9889
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLKES
Authorized Official First Name:
RENESSA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
318-473-0863

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 61350 . This is a "BCBS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com