Basic Information
| Provider Information | |||||||||
| NPI: | 1114109378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIAL CARE SERVICES OF LOUISIANA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRECISION CAREGIVERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2142 ONEAL LN | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252788375 | ||||||||
| FaxNumber: | 2252753251 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 PLANK RD | ||||||||
| Address2: | |||||||||
| City: | ST. JOSEPH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187669396 | ||||||||
| FaxNumber: | 3187669499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROACH | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | LAMB | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2252788375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | PCA 14025 | LA | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 1009652 | 05 | LA | MEDICAID |