MEDICARE: EAST LOUISIANA STATE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	283Q00000X	Psychiatric Hospital	201	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043206543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LOUISIANA STATE HOSPITAL

Provider Business Mailing Address
First Line	:	P.O. BOX 498
Second Line	:	4502 HIGHWAY 951
City	:	JACKSON
State	:	LA
Zip	:	70748-0498
Country	:	US
Telephone Number	:	225-634-0533
Fax Number	:	225-634-5827

Provider Business Practice Location Address
First Line	:	4502 HIGHWAY 951
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-0498
Country	:	US
Telephone Number	:	225-634-0533
Fax Number	:	225-634-5827

Authorized Official
Title or Position	:	ACCOUNTANT MANAGER 3
Name	:	MRS. MALISSA C. COLEMAN
Credential	:	B.S.
Telephone Number	:	225-634-0533

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	02/07/2011

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Directions to “EAST LOUISIANA STATE HOSPITAL ” Practice Location

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