=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407171515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAQUEMINE PSYCHIATRIC SERVICE. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2010
-----------------------------------------------------
Last Update Date | 03/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58005 MERIAM ST
-----------------------------------------------------
City | PLAQUEMINE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70764-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-892-6119
-----------------------------------------------------
Fax | 225-928-5793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1813 ROSALE DR
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70806-8566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-892-6119
-----------------------------------------------------
Fax | 225-928-5793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. DAVID L HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-892-6119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------