1457789802 NPI number — IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY

Table of content: ELIAS DAHHAM RPH (NPI 1245683465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457789802 NPI number — IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
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:
6
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:
1457789802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3505 5TH AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70607-2156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-475-3100
Provider Business Mailing Address Fax Number:
337-475-3105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3505 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70607-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-475-3100
Provider Business Practice Location Address Fax Number:
337-475-3105
Provider Enumeration Date:
10/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCGEE
Authorized Official First Name:
TANYA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
337-475-3100

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  95 , 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: 1710041 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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