Healthcare Provider Details

I. General information

NPI: 1447376926
Provider Name (Legal Business Name): LOUISE S DAVIS RESIDENTIAL FACILITIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 CLAIBORNE AVE
SHREVEPORT LA
71103-4203
US

IV. Provider business mailing address

1 LAKESHORE DR SUITE 1900
LAKE CHARLES LA
70629-0100
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-6600
  • Fax: 337-439-6647
Mailing address:
  • Phone: 337-439-6600
  • Fax: 337-439-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number973
License Number StateLA

VIII. Authorized Official

Name: KENDALL A BROUSSARD
Title or Position: MANAGING MEMBER
Credential:
Phone: 337-439-6600