Healthcare Provider Details

I. General information

NPI: 1629395116
Provider Name (Legal Business Name): BLUE HERON CHRONIC HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S LEMANS ST
LAFAYETTE LA
70503-4130
US

IV. Provider business mailing address

104 S LEMANS ST
LAFAYETTE LA
70503-4130
US

V. Phone/Fax

Practice location:
  • Phone: 337-298-4112
  • Fax: 337-233-1900
Mailing address:
  • Phone: 337-298-4112
  • Fax: 337-233-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberRN049882
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN049882
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number8172
License Number StateLA

VIII. Authorized Official

Name: MS. MARGARET GARDINER MITCHELL
Title or Position: ADMINISTRATOR
Credential: REGISTERED NURSE
Phone: 337-298-4112