Provider Demographics
NPI:1164796033
Name:MATTHEW 2540 CORPORATION
Entity Type:Organization
Organization Name:MATTHEW 2540 CORPORATION
Other - Org Name:NEPENTHE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, MSSA
Authorized Official - Phone:337-439-3061
Mailing Address - Street 1:1414 MARTHA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2440
Mailing Address - Country:US
Mailing Address - Phone:337-439-3061
Mailing Address - Fax:337-439-4279
Practice Address - Street 1:1414 MARTHA ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2440
Practice Address - Country:US
Practice Address - Phone:337-439-3061
Practice Address - Fax:337-439-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA184251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health