Provider Demographics
NPI:1285630129
Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Other - Org Name:IMAGING CENTER OF SOUTH LOUISIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-850-6805
Mailing Address - Street 1:PO BOX 4051
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4051
Mailing Address - Country:US
Mailing Address - Phone:985-917-3007
Mailing Address - Fax:985-917-3010
Practice Address - Street 1:128 NEUROSCIENCE CT
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359
Practice Address - Country:US
Practice Address - Phone:985-917-3007
Practice Address - Fax:985-917-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1947482Medicaid
LA5F903Medicare UPIN
LA5375590001Medicare NSC