Provider Demographics
NPI:1114003050
Name:NATCHITOCHES OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:NATCHITOCHES OUTPATIENT SERVICES
Other - Org Name:PRISM CENTER NATCHITOCHES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-214-4200
Mailing Address - Street 1:PO BOX 2154
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-2154
Mailing Address - Country:US
Mailing Address - Phone:318-214-4200
Mailing Address - Fax:318-214-4493
Practice Address - Street 1:740 KEYSER AVE
Practice Address - Street 2:SUITE E
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6037
Practice Address - Country:US
Practice Address - Phone:318-214-0088
Practice Address - Fax:318-214-4493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1524069Medicaid
LA1524069Medicaid
LA194545Medicare ID - Type UnspecifiedMEDICAIRE PRISM NATCH