Healthcare Provider Details

I. General information

NPI: 1285630129
Provider Name (Legal Business Name): SOUTHEAST NEUROSCIENCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 NEUROSCIENCE CT
GRAY LA
70359
US

IV. Provider business mailing address

PO BOX 4051
HOUMA LA
70361-4051
US

V. Phone/Fax

Practice location:
  • Phone: 985-917-3007
  • Fax: 985-917-3010
Mailing address:
  • Phone: 985-917-3007
  • Fax: 985-917-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. GABRIEL LEE NUGENT
Title or Position: DIRECTOR
Credential:
Phone: 985-850-6805