MEDICARE: IBL SPECIAL CARE MANAGEMENT SERVICES

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	302F00000X	Exclusive Provider Organization	PCA 15172	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	:	1306083894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IBL SPECIAL CARE MANAGEMENT SERVICES

Provider Business Mailing Address
First Line	:	14241 COURSEY BLVD
Second Line	:	STE A12167
City	:	BATON ROUGE
State	:	LA
Zip	:	70817-1368
Country	:	US
Telephone Number	:	225-291-3123
Fax Number	:	225-291-3069

Provider Business Practice Location Address
First Line	:	11616 SOUTHFORK AVE
Second Line	:	STE 204
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-5241
Country	:	US
Telephone Number	:	225-291-3123
Fax Number	:	225-291-3069

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. SAMANTHA ANN ROACH
Credential	:
Telephone Number	:	225-291-3123

Provider Enumeration Date	:	01/21/2009
Last Update Date	:	02/04/2009

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Directions to “IBL SPECIAL CARE MANAGEMENT SERVICES ” Practice Location

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