| NPI | 1407074164 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SUZANNE DICKERSON Program Coordinator 985-876-0559 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: LA 12649) |
| Enumeration Date | 2007-04-20 |
| Last Update Date | 2020-08-22 |