Provider Demographics
NPI:1417113267
Name:ST. MATTHEW'S DIRECT CARE SERVICE
Entity Type:Organization
Organization Name:ST. MATTHEW'S DIRECT CARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:V
Authorized Official - Last Name:SNEED-MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-213-2273
Mailing Address - Street 1:2620 CENTENARY BLVD
Mailing Address - Street 2:BLDG 1 SUITE 104
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3356
Mailing Address - Country:US
Mailing Address - Phone:318-213-2273
Mailing Address - Fax:318-213-2275
Practice Address - Street 1:2620 CENTENARY BLVD
Practice Address - Street 2:BLDG 1 SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3356
Practice Address - Country:US
Practice Address - Phone:318-213-2273
Practice Address - Fax:318-213-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20081302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA20081Medicaid