Healthcare Provider Details

I. General information

NPI: 1245401306
Provider Name (Legal Business Name): SOUTHEAST LOUISIANA AHEC FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 J W DAVIS DR
HAMMOND LA
70403-5914
US

IV. Provider business mailing address

1302 J W DAVIS DR
HAMMOND LA
70403-5914
US

V. Phone/Fax

Practice location:
  • Phone: 985-345-1119
  • Fax:
Mailing address:
  • Phone: 985-345-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number1175790
License Number StateLA

VIII. Authorized Official

Name: MR. BRIAN PETER JAKES SR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: BFA
Phone: 985-345-1119