1215058565 NPI number — THE ARC - IBERVILLE

Table of content: (NPI 1215058565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215058565 NPI number — THE ARC - IBERVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE ARC - IBERVILLE
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:
1215058565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 264
Provider Second Line Business Mailing Address:
24615 J. GERALD BERRET BLVD
Provider Business Mailing Address City Name:
PLAQUEMINE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70765-0264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-687-4062
Provider Business Mailing Address Fax Number:
225-687-3272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24615 J. GERALD BERRET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAQUEMINE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-687-4062
Provider Business Practice Location Address Fax Number:
225-687-3272
Provider Enumeration Date:
04/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FUSSELL
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
225-687-6042

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  2271 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: 2424 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1911704 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".