Basic Information
| Provider Information | |||||||||
| NPI: | 1457413635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADIANA CONCERN FOR AIDS RELIEF EDUCATION AND SUPPORT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3865 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705023865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372332437 | ||||||||
| FaxNumber: | 3372354178 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 MARTIN LUTHER KING JR DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705011884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372332437 | ||||||||
| FaxNumber: | 3372354178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | CLAUDE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3372332437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | CM4010 | LA | N | Agencies | Case Management | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | SA0008130 | LA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1109711 | 05 | LA | MEDICAID | 600749121 | 01 | LA | MGL MIS | OTHER |