Provider Demographics
NPI:1851538342
Name:IBL SPECIAL CARE MANAGEMENT SERVICES
Entity Type:Organization
Organization Name:IBL SPECIAL CARE MANAGEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-291-3123
Mailing Address - Street 1:14241 COURSEY BLVD
Mailing Address - Street 2:STE A12167
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1368
Mailing Address - Country:US
Mailing Address - Phone:225-291-3123
Mailing Address - Fax:225-291-3069
Practice Address - Street 1:11616 SOUTHFORK AVE
Practice Address - Street 2:STE 204
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5241
Practice Address - Country:US
Practice Address - Phone:225-291-3123
Practice Address - Fax:225-291-3069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 15172302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPC0007839Medicaid