Healthcare Provider Details

I. General information

NPI: 1366610719
Provider Name (Legal Business Name): MANGHAM HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 BROADWAY STREET
MANGHAM LA
71259
US

IV. Provider business mailing address

P,O. BOX 427
MANGHAM LA
71259
US

V. Phone/Fax

Practice location:
  • Phone: 318-248-2849
  • Fax: 318-248-2852
Mailing address:
  • Phone: 318-248-2849
  • Fax: 318-248-2852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPCA 10355
License Number StateLA

VIII. Authorized Official

Name: MS. IDA GILLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-248-2849