=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275893778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE AGAPE HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2012
-----------------------------------------------------
Last Update Date | 05/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 MORRIS ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70538-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-828-0672
-----------------------------------------------------
Fax | 337-828-4750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508 MORRIS ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70538-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-828-0672
-----------------------------------------------------
Fax | 337-828-4750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EX. DIRECTOR
-----------------------------------------------------
Name | MRS. DAWNISHA ELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-578-3372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 13553
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------