Healthcare Provider Details

I. General information

NPI: 1922151091
Provider Name (Legal Business Name): CASANDRA KIMBERLAIN TUMBLIN B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VIRGINIAN COLONY AVE
LA PLACE LA
70068-2843
US

IV. Provider business mailing address

1805 VIRGINIAN COLONY AVE
LA PLACE LA
70068-2843
US

V. Phone/Fax

Practice location:
  • Phone: 985-210-3358
  • Fax: 985-653-8494
Mailing address:
  • Phone: 985-653-8494
  • Fax: 985-653-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number005181316
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: