=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649810581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISIONARIES IMPACTING PEOPLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2020
-----------------------------------------------------
Last Update Date | 01/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 W COTTON ST
-----------------------------------------------------
City | VILLE PLATTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70586-4442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-831-3098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 W COTTON ST
-----------------------------------------------------
City | VILLE PLATTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70586-4442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-831-3098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MATTHEW ALFRED JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-831-3098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------