=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316129828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMISE PRIDE ENTERPRISES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2007
-----------------------------------------------------
Last Update Date | 11/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 GROOM RD
-----------------------------------------------------
City | BAKER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70714-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-774-3385
-----------------------------------------------------
Fax | 225-774-7381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 GROOM RD
-----------------------------------------------------
City | BAKER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70714-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-774-3385
-----------------------------------------------------
Fax | 225-774-7381
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR/ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MARY E. WHITE
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 225-774-3385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | ADHC 5039
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------