1881968519 NPI number — ASSISI BRIDGE HOUSE INDEPENDENT LIVING PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881968519 NPI number — ASSISI BRIDGE HOUSE INDEPENDENT LIVING PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSISI BRIDGE HOUSE INDEPENDENT LIVING PROGRAM
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:
1881968519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 AYCOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUMA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70360-6402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-876-0490
Provider Business Mailing Address Fax Number:
985-876-7751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 LEVRON ST APT 12D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70360-5574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-872-5529
Provider Business Practice Location Address Fax Number:
985-857-8270
Provider Enumeration Date:
02/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GORMAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
DAMIEN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
985-876-0490

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  2437 , 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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