Provider Demographics
NPI:1992857494
Name:LAFOURCHE ARC
Entity Type:Organization
Organization Name:LAFOURCHE ARC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BONVILLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-447-6214
Mailing Address - Street 1:100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-5216
Mailing Address - Country:US
Mailing Address - Phone:985-447-6214
Mailing Address - Fax:985-447-4813
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5216
Practice Address - Country:US
Practice Address - Phone:985-447-6214
Practice Address - Fax:985-447-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6791320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1176095Medicaid