1154816908 NPI number — LAUVES PPECC LLC

Table of content: (NPI 1154816908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154816908 NPI number — LAUVES PPECC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUVES PPECC 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:
LAUVE'S PEDIATRIC EXTENDED CARE
Provider Other Organization Name Type Code:
3
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:
1154816908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
435 MONROVIA ST
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:
71106-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-465-5494
Provider Business Mailing Address Fax Number:
318-741-5757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 ENTERPRISE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75604-5463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-465-5494
Provider Business Practice Location Address Fax Number:
318-383-1215
Provider Enumeration Date:
06/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LAUVE
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
SIMON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-465-5494

Provider Taxonomy Codes

  • Taxonomy code: 261QM3000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4017402-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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