Healthcare Provider Details

I. General information

NPI: 1043472608
Provider Name (Legal Business Name): IMMANUELS HEALING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 FERRAND ST STE 23
MONROE LA
71201-3233
US

IV. Provider business mailing address

2404 FERRAND STREET SUITE 23
MONROE LA
71201
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-0463
  • Fax: 318-323-0465
Mailing address:
  • Phone: 318-323-0463
  • Fax: 318-323-0465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KELVIN HORNE
Title or Position: OWNER
Credential:
Phone: 318-323-0463