Organization
1ST A SOUTHEAST INCS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SUZANNE DICKERSON (PROGRAM COORDINATOR)
(985) 876-0559
Entity
Organization
Contact information
Practice address
614 ROUSSELL ST, HOUMA, LA 70360-4556
(985) 876-0559
Mailing address
614 ROUSSELL ST, HOUMA, LA 70360-4556
(985) 876-0559
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
12649
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1169145
—
LA
Enumeration date
04/20/2007
Last updated
08/22/2020
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