=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073403846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POOLE HOME & RETREAT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2025
-----------------------------------------------------
Last Update Date | 11/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 POOLE RD
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71052-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-750-6549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 TRINITY WAY APT B13
-----------------------------------------------------
City | RUSTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71270-7313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-750-6549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SHAMBRICAL K GRIFFIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-750-6549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------