Provider Demographics
NPI:1366820367
Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-917-3007
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:985-917-3001
Mailing Address - Fax:985-917-3007
Practice Address - Street 1:8120 MAIN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3403
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:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty