Provider Demographics
NPI:1801892716
Name:GENESIS OF NEW IBERIA INC.
Entity type:Organization
Organization Name:GENESIS OF NEW IBERIA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ARLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-237-4673
Mailing Address - Street 1:847 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-8539
Mailing Address - Country:US
Mailing Address - Phone:337-237-4673
Mailing Address - Fax:337-237-4674
Practice Address - Street 1:224 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2841
Practice Address - Country:US
Practice Address - Phone:337-237-4673
Practice Address - Fax:337-237-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1118991261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1118991Medicaid
LA194684Medicare ID - Type UnspecifiedCMHC