Provider Demographics
NPI:1457473340
Name:THE ARC - IBERVILLE
Entity Type:Organization
Organization Name:THE ARC - IBERVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:225-687-6042
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:24615 J. GERALD BERRET BLVD
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70765-0264
Mailing Address - Country:US
Mailing Address - Phone:225-687-4062
Mailing Address - Fax:225-687-3272
Practice Address - Street 1:24615 J. GERALD BERRET BLVD
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764
Practice Address - Country:US
Practice Address - Phone:225-687-4062
Practice Address - Fax:225-687-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2271251C00000X
LA2424251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1950335Medicaid