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General NPI Number Information
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NPI Number | 1649496142
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Entity Type | Organization
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Legal Business Name | MARY MARCOMBE HOME
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1030 CLAY ST
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City | DONALDSONVILLE
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State | LA
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Zip | 70346-3518
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Country | US
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Telephone | 225-473-4516
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Fax | 225-473-4517
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Provider Business Mailing Address
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Address Line | 1030 CLAY ST PO BOX 624
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City | DONALDSONVILLE
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State | LA
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Zip | 70346-3518
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Country | US
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Telephone | 225-473-4516
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Fax | 225-473-4517
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. MARLENE BENOIT DOMINGUE
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Credential | RN
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Telephone | 225-473-4516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 495
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License Number State | LA
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