MEDICARE: SME COALITION FOR CHANGE LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1306625868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SME COALITION FOR CHANGE LLC

Provider Business Mailing Address
First Line	:	12278 PLANK RD.
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70811-1035
Country	:	US
Telephone Number	:	225-364-9428
Fax Number	:	225-341-6797

Provider Business Practice Location Address
First Line	:	12278 PLANK RD.
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70811-1035
Country	:	US
Telephone Number	:	225-364-9428
Fax Number	:	225-341-6797

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	MRS. SUSIE ETHELIN KING-DUNCAN
Credential	:	LMSW
Telephone Number	:	210-240-3198

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	01/30/2024

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