Provider Demographics
NPI:1467670869
Name:NORTHWEST SUPPORTS AND SERVICES CENTER
Entity Type:Organization
Organization Name:NORTHWEST SUPPORTS AND SERVICES CENTER
Other - Org Name:NORTHWEST LOUISIANA DEVELOPMENTAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-741-5200
Mailing Address - Street 1:5401 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5420
Mailing Address - Country:US
Mailing Address - Phone:318-741-5230
Mailing Address - Fax:318-741-7303
Practice Address - Street 1:5401 SHED RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5420
Practice Address - Country:US
Practice Address - Phone:318-741-5230
Practice Address - Fax:318-741-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1607320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567230Medicaid
LA1156761Medicaid
LA1408182Medicaid
LA1712035Medicaid
LA1156752Medicaid