Healthcare Provider Details

I. General information

NPI: 1346429990
Provider Name (Legal Business Name): IMMACULATE HEART OF MARY-PCS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 LYONS ST
MELVILLE LA
71353
US

IV. Provider business mailing address

PO BOX 668
MELVILLE LA
71353-0668
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 Code372600000X
TaxonomyAdult Companion
License Number12145
License Number StateLA

VIII. Authorized Official

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