=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902080146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROYALTY PERSONAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2007
-----------------------------------------------------
Last Update Date | 12/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1532 S BURNSIDE AVE BLDG 10A
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-677-9769
-----------------------------------------------------
Fax | 225-313-3488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1532 SOUTH BURNSIDE AVE.SUITE 10 A
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-677-9769
-----------------------------------------------------
Fax | 225-313-3488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM ADMINISTRATOR
-----------------------------------------------------
Name | SHANNON WILLIAMS SIMMONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-803-8217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | PCA 14063
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------