Provider Demographics
NPI:1689843435
Name:AUTHENTIC COMMUNITY LIVING, INC.
Entity Type:Organization
Organization Name:AUTHENTIC COMMUNITY LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:WATSON
Authorized Official - Last Name:DIBIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-368-4535
Mailing Address - Street 1:1799 STUMPF BLVD
Mailing Address - Street 2:BLDG.7 SUITE 1
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-3950
Mailing Address - Country:US
Mailing Address - Phone:504-368-4535
Mailing Address - Fax:504-368-4560
Practice Address - Street 1:1799 STUMPF BLVD
Practice Address - Street 2:BLDG.7 SUITE 1
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-368-4535
Practice Address - Fax:504-368-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA96413747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567337Medicaid
LA1567345Medicaid
LA1173410Medicaid