Provider Demographics
NPI:1407074164
Name:1ST A SOUTHEAST INCS, LLC
Entity Type:Organization
Organization Name:1ST A SOUTHEAST INCS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-876-0559
Mailing Address - Street 1:614 ROUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4556
Mailing Address - Country:US
Mailing Address - Phone:985-876-0559
Mailing Address - Fax:
Practice Address - Street 1:614 ROUSSELL ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4556
Practice Address - Country:US
Practice Address - Phone:985-876-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12649305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169145Medicaid