1558589952 NPI number — NORTHWEST SUPPORTS AND SERVICES CENTER

Table of content: (NPI 1558589952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558589952 NPI number — NORTHWEST SUPPORTS AND SERVICES CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST SUPPORTS AND SERVICES CENTER
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:
NORTHWEST LOUISIANA DEVELOPMENTAL CENTER
Provider Other Organization Name Type Code:
4
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:
1558589952
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 SHED RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71111-5420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-741-5230
Provider Business Mailing Address Fax Number:
318-741-7303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 SHED RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-741-5230
Provider Business Practice Location Address Fax Number:
318-741-7303
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COLVIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
318-741-5200

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  12703 , 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: 1408182 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1712035 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1156761 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1156752 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1567230 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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