Provider Demographics
NPI:1871732628
Name:NORTHWEST SUPPORTS AND SERVICES CENTER
Entity type:Organization
Organization Name:NORTHWEST SUPPORTS AND SERVICES CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-741-5200
Mailing Address - Street 1:5401 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5420
Mailing Address - Country:US
Mailing Address - Phone:318-741-5230
Mailing Address - Fax:318-741-5303
Practice Address - Street 1:5401 SHED RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5420
Practice Address - Country:US
Practice Address - Phone:318-741-5230
Practice Address - Fax:318-741-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency