=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215312996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY'S HEALTHCARE MINISTRIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2015
-----------------------------------------------------
Last Update Date | 07/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 HEYMAN LN
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-3523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-730-2336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 HEYMAN LN
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-3523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-730-2336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. LYDA CAROL HIRCHAK
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 318-730-2336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------