Provider Demographics
NPI:1861726598
Name:NORTHEAST SUPPORTS AND SERVICES CENTER
Entity type:Organization
Organization Name:NORTHEAST SUPPORTS AND SERVICES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-247-4213
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-0907
Mailing Address - Country:US
Mailing Address - Phone:318-247-4213
Mailing Address - Fax:318-247-4254
Practice Address - Street 1:2776 HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-1500
Practice Address - Country:US
Practice Address - Phone:318-247-4213
Practice Address - Fax:318-247-4254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1886726Medicaid