Healthcare Provider Details

I. General information

NPI: 1831477405
Provider Name (Legal Business Name): IMMACULATE HEART OF MARY-PCS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 LYONS STREET
MELVILLE LA
71353
US

IV. Provider business mailing address

P.O. BOX 670
MELVILLE LA
71353-0670
US

V. Phone/Fax

Practice location:
  • Phone: 337-623-4100
  • Fax: 337-623-4102
Mailing address:
  • Phone: 337-623-4100
  • Fax: 337-623-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License NumberPCA 12145
License Number StateLA

VIII. Authorized Official

Name: BENNETT WADE MORAIN
Title or Position: OWNER
Credential:
Phone: 337-623-4100