Provider Demographics
NPI:1992184501
Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEAST NEUROSCIENCE CENTER, LLC
Other - Org Name:SOUTHEAST NEUROSCIENCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-850-6805
Mailing Address - Street 1:PO BOX 4051
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4051
Mailing Address - Country:US
Mailing Address - Phone:985-917-3007
Mailing Address - Fax:985-917-3010
Practice Address - Street 1:1126 MARGUERITE ST
Practice Address - Street 2:SUITE A
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1891
Practice Address - Country:US
Practice Address - Phone:985-917-3007
Practice Address - Fax:985-702-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1947482Medicaid
LA5F903Medicare PIN