Provider Demographics
NPI:1225782196
Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Other - Org Name:BASTROP INTEGRATED CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE PROGRAM SPECIALIST B
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-362-3270
Mailing Address - Street 1:450 E PINE STREET
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-3840
Mailing Address - Country:US
Mailing Address - Phone:318-283-0868
Mailing Address - Fax:318-283-0875
Practice Address - Street 1:450 E PINE STREET
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3840
Practice Address - Country:US
Practice Address - Phone:318-283-0868
Practice Address - Fax:318-283-0875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1750051Medicaid