=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528564184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSE OF JUDAH INTERNATIONAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2018
-----------------------------------------------------
Last Update Date | 04/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4104 SPURGEON DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-343-6751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4104 SPURGEON DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JONAH WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-344-9145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------