Healthcare Provider Details

I. General information

NPI: 1952424954
Provider Name (Legal Business Name): IMMACULATE HEART OF MARY-PCS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 LYONS ST.
MELVILLE LA
71353-0670
US

IV. Provider business mailing address

PO BOX 670
MELVILLE LA
71353-0670
US

V. Phone/Fax

Practice location:
  • Phone: 337-623-4100
  • Fax: 337-623-4102
Mailing address:
  • Phone: 337-623-4109
  • Fax: 337-623-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number12145
License Number StateLA

VIII. Authorized Official

Name: MR. BENNETT MORIAN
Title or Position: OWNER
Credential:
Phone: 337-623-4109