Healthcare Provider Details

I. General information

NPI: 1417158775
Provider Name (Legal Business Name): IMMACULATE HEART OF MARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 NORTH HWY 1
MORGANZA LA
70759-0505
US

IV. Provider business mailing address

PO BOX 505
MORGANZA LA
70759-0505
US

V. Phone/Fax

Practice location:
  • Phone: 225-694-0010
  • Fax: 337-623-4102
Mailing address:
  • Phone: 225-694-0010
  • Fax: 337-623-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1621676
License Number StateLA

VIII. Authorized Official

Name: MRS. DANIELLE SANDERS
Title or Position: SUPERVISOR
Credential:
Phone: 337-623-4100