=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386460186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONROE AND MAGGIE HOUSE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2024
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2614 HIGHWAY 952
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70748-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-719-8164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2614 HIGHWAY 952
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70748-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-719-8164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. TYRIE DUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-719-8164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------