Provider Demographics
NPI:1477894905
Name:IHSC @ LASALLE DETENTION FACILITY
Entity Type:Organization
Organization Name:IHSC @ LASALLE DETENTION FACILITY
Other - Org Name:STG INTERNATIONAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CDR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:318-992-7612
Mailing Address - Street 1:830 PINEHILL RD
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-4137
Mailing Address - Country:US
Mailing Address - Phone:318-992-7613
Mailing Address - Fax:
Practice Address - Street 1:830 PINEHILL RD
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-4137
Practice Address - Country:US
Practice Address - Phone:318-992-7613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty