Basic Information
| Provider Information | |||||||||
| NPI: | 1063569648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTNEUROPSYCHADVANCED HC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2829 4TH AVE | ||||||||
| Address2: | 150 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374777091 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 4TH AVE | ||||||||
| Address2: | 150 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374777091 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ARCHER | ||||||||
| AuthorizedOfficialFirstName: | DEWEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENTCEO | ||||||||
| AuthorizedOfficialTelephone: | 3374777091 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ADC6247 | LA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1551228 | 05 | LA | MEDICAID |