Healthcare Provider Details

I. General information

NPI: 1619196383
Provider Name (Legal Business Name): HOLY ANGELS RESIDENTIAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 ELLERBE RD
SHREVEPORT LA
71106-7712
US

IV. Provider business mailing address

10450 ELLERBE RD
SHREVEPORT LA
71106-7712
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-8500
  • Fax: 318-798-0159
Mailing address:
  • Phone: 318-797-8500
  • Fax: 318-798-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number929
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA LANDRY HORNE
Title or Position: DIRECTOR OF FINANCE
Credential: CPA
Phone: 318-797-8500