Provider Demographics
NPI:1619182458
Name:SOUTHWEST LOUISIANA INDEPENDENCE CENTER INC.
Entity Type:Organization
Organization Name:SOUTHWEST LOUISIANA INDEPENDENCE CENTER INC.
Other - Org Name:@SLIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DARTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-477-7194
Mailing Address - Street 1:4320 LAKE ST.
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-477-7194
Mailing Address - Fax:337-477-7198
Practice Address - Street 1:4320 LAKE ST.
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-477-7194
Practice Address - Fax:337-477-7198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LASIL7163251B00000X
251C00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1009521Medicaid