1790905545 NPI number — EASTERN LA. MENTAL HEALTH SYSTEM COMMUNITY HOMES DIVISION

Table of content: (NPI 1790905545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790905545 NPI number — EASTERN LA. MENTAL HEALTH SYSTEM COMMUNITY HOMES DIVISION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN LA. MENTAL HEALTH SYSTEM COMMUNITY HOMES DIVISION
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:
W. T. PRICE SR., RESIDENCE # 99
Provider Other Organization Name Type Code:
5
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:
1790905545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70748-0498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-634-0661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4502 HWY. 951
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70748-0498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-634-0661
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRELL
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
ADM. CO. 4
Authorized Official Telephone Number:
225-634-0661

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  697 , 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: 1712299 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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