1275690125 NPI number — COMMCARE LOUISIANA

Table of content: (NPI 1275690125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275690125 NPI number — COMMCARE LOUISIANA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMCARE LOUISIANA
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:
6
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:
1275690125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 GREEWOOD ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71109-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-631-1466
Provider Business Mailing Address Fax Number:
318-631-9466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201A SHREVEPORT HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-640-2030
Provider Business Practice Location Address Fax Number:
318-640-4927
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STASSI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
SECRETARY AND DIRECTOR
Authorized Official Telephone Number:
504-324-8950

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2730984-001 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 30440-011-0-2010 , 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: 1473715 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1677531 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com