Provider Demographics
NPI:1356481394
Name:ACADIANA REGION SUPPORTS & SERVICES CENTER
Entity Type:Organization
Organization Name:ACADIANA REGION SUPPORTS & SERVICES CENTER
Other - Org Name:OPELOUSAS COMMUNITY HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:MR DD REGIONAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-824-6250
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:224 GREMILLION CIRCLE
Mailing Address - City:IOTA
Mailing Address - State:LA
Mailing Address - Zip Code:70543-0218
Mailing Address - Country:US
Mailing Address - Phone:337-824-6250
Mailing Address - Fax:337-821-9306
Practice Address - Street 1:1107 W. LINWOOD DR
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6919
Practice Address - Country:US
Practice Address - Phone:337-821-9301
Practice Address - Fax:337-821-9306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA319320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1712175Medicaid