MEDICARE: MEDICAL MALL HEALTH SERVICES OF LOUISIANA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	261QC1500X	Community Health Clinic/Center
3	347C00000X	Private Vehicle
4	251B00000X	Case Management Agency
5	251E00000X	Home Health Agency
6	251G00000X	Community Based Hospice Care Agency
7	251J00000X	Nursing Care Agency
8	251K00000X	Public Health or Welfare Agency
9	251X00000X	Supports Brokerage Agency
10	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073232849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL MALL HEALTH SERVICES OF LOUISIANA

Provider Business Mailing Address
First Line	:	3745 CHOCTAW DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70805-8333
Country	:	US
Telephone Number	:	225-806-6923
Fax Number	:	225-372-8105

Provider Business Practice Location Address
First Line	:	3745 CHOCTAW DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70805-8333
Country	:	US
Telephone Number	:	225-806-6923
Fax Number	:	225-372-8105

Authorized Official
Title or Position	:	OWNER
Name	:	HAROLD WILLIAMS
Credential	:
Telephone Number	:	225-806-6923

Provider Enumeration Date	:	08/25/2022
Last Update Date	:	08/25/2022

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