1306625868 NPI number — SME COALITION FOR CHANGE LLC

Table of content: BJIOURN BORG BUGAYONG APRN (NPI 1649933714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306625868 NPI number — SME COALITION FOR CHANGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SME COALITION FOR CHANGE 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:
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:
1306625868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12278 PLANK RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70811-1035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-364-9428
Provider Business Mailing Address Fax Number:
225-341-6797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12278 PLANK RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70811-1035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-364-9428
Provider Business Practice Location Address Fax Number:
225-341-6797
Provider Enumeration Date:
09/25/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KING-DUNCAN
Authorized Official First Name:
SUSIE
Authorized Official Middle Name:
ETHELIN
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
210-240-3198

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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