Provider Demographics
NPI:1902024656
Name:NORTHSHORE INCS, LLC
Entity Type:Organization
Organization Name:NORTHSHORE INCS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-639-1605
Mailing Address - Street 1:742 E I 10 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5518
Mailing Address - Country:US
Mailing Address - Phone:985-649-1605
Mailing Address - Fax:
Practice Address - Street 1:742 E I 10 SERVICE RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5518
Practice Address - Country:US
Practice Address - Phone:985-649-1605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10386305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171956Medicaid