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General NPI Number Information
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NPI Number | 1063624625
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Entity Type | Organization
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Legal Business Name | FIELDS DE LA NARURLAE
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2828 GAY DR
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City | MONROE
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State | LA
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Zip | 71202-6765
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Country | US
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Telephone | 318-322-1910
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Fax | 318-322-1910
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Provider Business Mailing Address
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Address Line | 3660 HADLEY ST
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City | MONROE
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State | LA
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Zip | 71202-4556
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Country | US
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Telephone | 318-322-1910
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Fax | 318-322-1910
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Authorized Official
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Title or Position | QMRP
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Name | MRS. JEANETTE LITTLE MYLES
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Credential | S.W.
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Telephone | 318-322-1910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 192
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License Number State | LA
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