Healthcare Provider Details

I. General information

NPI: 1538235429
Provider Name (Legal Business Name): MANGHAM HOME CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 BROADWAY
MANGHAM LA
71259
US

IV. Provider business mailing address

PO BOX 427 714 BROADWAY
MANGHAM LA
71259-0427
US

V. Phone/Fax

Practice location:
  • Phone: 318-248-2797
  • Fax:
Mailing address:
  • Phone: 318-248-2797
  • Fax: 318-248-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number377
License Number StateLA

VIII. Authorized Official

Name: MS. IDA GILLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-248-2797