1649889536 NPI number — ELIJAH B EVANS PEER SUPPORT CERT.

Table of content: ELIJAH B EVANS PEER SUPPORT CERT. (NPI 1649889536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649889536 NPI number — ELIJAH B EVANS PEER SUPPORT CERT.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
ELIJAH
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PEER SUPPORT CERT.
Provider Gender Code:
M

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:
1649889536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122A OLIVE BRANCH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70592-5121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-376-3523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 W HUTCHINSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWLEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70526-4124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-250-4263
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  011576884 , 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)





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