Basic Information
| Provider Information | |||||||||
| NPI: | 1912136730 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIAL CARE SERVICES OF LOUISIANA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRECISION CAREGIVERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2142 ONEAL LN | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257564494 | ||||||||
| FaxNumber: | 2257564495 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 PLANK RD | ||||||||
| Address2: | |||||||||
| City: | ST. JOSEPH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187669396 | ||||||||
| FaxNumber: | 3187669499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROACH | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | LAMB | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252788375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | SIL 20180 | LA | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | PCA 14025 | 05 | LA | MEDICAID | SIL 20180 | 05 | LA | MEDICAID |