Provider Demographics
NPI:1134279276
Name:SAMARITAN COUNSELING CENTER OF IMPERIAL CALCASIEU
Entity Type:Organization
Organization Name:SAMARITAN COUNSELING CENTER OF IMPERIAL CALCASIEU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:RENTROP
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:337-433-4357
Mailing Address - Street 1:833 HODGES ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4247
Mailing Address - Country:US
Mailing Address - Phone:337-433-4357
Mailing Address - Fax:337-433-9764
Practice Address - Street 1:833 HODGES ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4247
Practice Address - Country:US
Practice Address - Phone:337-433-4357
Practice Address - Fax:337-433-9764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center