1780075499 NPI number — SOUTHEASTERN LOUISIANA UNIVERISITY

Table of content: (NPI 1780075499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780075499 NPI number — SOUTHEASTERN LOUISIANA UNIVERISITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN LOUISIANA UNIVERISITY
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:
1780075499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650850
Provider Second Line Business Mailing Address:
DEPT. 1011
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-555-9073
Provider Business Mailing Address Fax Number:
972-367-3452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 GALLOWAY DR
Provider Second Line Business Practice Location Address:
DUGAS CENTER
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70402-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-549-5133
Provider Business Practice Location Address Fax Number:
972-367-3451
Provider Enumeration Date:
02/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
IRWIN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
ASST. DIRECTOR FOR SPORTS MEDICINE
Authorized Official Telephone Number:
985-549-5133

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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