Provider Demographics
NPI:1043206543
Name:EAST LOUISIANA STATE HOSPITAL
Entity Type:Organization
Organization Name:EAST LOUISIANA STATE HOSPITAL
Other - Org Name:EASTERN LA MENTAL HEALTH SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT MANAGER 3
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALISSA
Authorized Official - Middle Name:C
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:225-634-0533
Mailing Address - Street 1:P.O. BOX 498
Mailing Address - Street 2:4502 HIGHWAY 951
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748-0498
Mailing Address - Country:US
Mailing Address - Phone:225-634-0533
Mailing Address - Fax:225-634-5827
Practice Address - Street 1:4502 HIGHWAY 951
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748-0498
Practice Address - Country:US
Practice Address - Phone:225-634-0533
Practice Address - Fax:225-634-5827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710016Medicaid
LA194008Medicare Oscar/Certification
LA5D456Medicare PIN