Healthcare Provider Details

I. General information

NPI: 1942330642
Provider Name (Legal Business Name): ANGEL MANOR- BREAUX BRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 W BRIDGE ST
BREAUX BRIDGE LA
70517-5040
US

IV. Provider business mailing address

329 W BRIDGE ST
BREAUX BRIDGE LA
70517-5040
US

V. Phone/Fax

Practice location:
  • Phone: 337-332-3421
  • Fax: 337-332-3461
Mailing address:
  • Phone: 337-332-3421
  • Fax: 337-332-3461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number251C00000X
License Number StateLA

VIII. Authorized Official

Name: MR. JOHN SAMUEL FORD JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-332-3421