Provider Demographics
NPI:1245401306
Name:SOUTHEAST LOUISIANA AHEC FOUNDATION, INC
Entity Type:Organization
Organization Name:SOUTHEAST LOUISIANA AHEC FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:JAKES
Authorized Official - Suffix:SR
Authorized Official - Credentials:BFA
Authorized Official - Phone:985-345-1119
Mailing Address - Street 1:1302 J W DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5914
Mailing Address - Country:US
Mailing Address - Phone:985-345-1119
Mailing Address - Fax:
Practice Address - Street 1:1302 J W DAVIS DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5914
Practice Address - Country:US
Practice Address - Phone:985-345-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
LA1175790305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA117590Medicaid