1730307133 NPI number — NORTHWEST SUPPORTS AND SERVICES CENTER

Table of content: DR. ROGER ELLIOTT BELSON MD (NPI 1851490999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730307133 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:
1730307133
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:
318-741-5303

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:
318-741-5303
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:  SIL 12595 , 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: 1156752 , 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: 1567230 , 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".




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