Provider Demographics
NPI:1780075499
Name:SOUTHEASTERN LOUISIANA UNIVERISITY
Entity type:Organization
Organization Name:SOUTHEASTERN LOUISIANA UNIVERISITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST. DIRECTOR FOR SPORTS MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-549-5133
Mailing Address - Street 1:PO BOX 650850
Mailing Address - Street 2:DEPT. 1011
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0850
Mailing Address - Country:US
Mailing Address - Phone:800-555-9073
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:800 GALLOWAY DR
Practice Address - Street 2:DUGAS CENTER
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70402-0001
Practice Address - Country:US
Practice Address - Phone:985-549-5133
Practice Address - Fax:972-367-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty