Healthcare Provider Details

I. General information

NPI: 1851547566
Provider Name (Legal Business Name): MARTIN FAMILY SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 BLANKENSHIP ROAD
PLAIN DEALING LA
71064
US

IV. Provider business mailing address

P.O. BOX 515 248 BLANKENSHIP ROAD
PLAIN DEALING LA
71064
US

V. Phone/Fax

Practice location:
  • Phone: 318-326-4623
  • Fax:
Mailing address:
  • Phone: 318-326-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number15079
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number15079
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number20086
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15079
Identifier TypeOTHER
Identifier StateLA
Identifier IssuerCHILDREN'S CHOICE
# 2
Identifier0007762
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer
# 3
Identifier0007764
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name: MRS. MAPLE LEE MARTIN
Title or Position: PROGRAM MANAGER/OWNER
Credential:
Phone: 318-326-4623