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General NPI Number Information
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NPI Number | 1841434131
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Entity Type | Organization
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Legal Business Name | WILSON GROUP HOME
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Dates
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Enumeration Date | 04/30/2009
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Last Update Date | 11/05/2009
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Provider Practice Location Address
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Address Line | 502 BOYD STREET
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City | CHENEYVILLE
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State | LA
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Zip | 71325
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Country | US
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Telephone | 318-279-2464
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Fax | 318-279-2465
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Provider Business Mailing Address
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Address Line | PO BOX 7917
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City | ALEXANDRIA
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State | LA
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Zip | 71306-0917
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Country | US
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Telephone | 318-445-1551
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Fax | 318-445-1242
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CHRISTINA BOLTON
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Credential |
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Telephone | 318-445-1551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 1056
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License Number State | LA
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