1366168973 NPI number — 2907 BASILE SNF LLC

Table of content: NICOLE MARIE ERICKSON LCSW (NPI 1265876288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366168973 NPI number — 2907 BASILE SNF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
2907 BASILE SNF 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:
1366168973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 VEROT SCHOOL RD STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-6466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-270-9090
Provider Business Mailing Address Fax Number:
337-270-9038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2907 SCHAMBERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASILE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70515-5445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-432-6663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AUTHORIZED AGENT
Authorized Official Telephone Number:
337-270-9090

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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