Provider Demographics
NPI:1275690125
Name:COMMCARE LOUISIANA
Entity Type:Organization
Organization Name:COMMCARE LOUISIANA
Other - Org Name:D/B/A HOME INFUSION AND DME SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY AND DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STASSI
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:504-324-8950
Mailing Address - Street 1:4020 GREEWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-0000
Mailing Address - Country:US
Mailing Address - Phone:318-631-1466
Mailing Address - Fax:318-631-9466
Practice Address - Street 1:5201A SHREVEPORT HIGHWAY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-640-2030
Practice Address - Fax:318-640-4927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMCARE LOUISIANA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2730984-001332B00000X
LA30440-011-0-2010332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473715Medicaid
LA1677531Medicaid
LA1473715Medicaid