MEDICARE: SHEKINAH GLORY MINISTRY OF BATON ROUGE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	SIL 12514	LA
2	320700000X	Physical Disabilities Residential Treatment Facility	PCA 12390	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184841488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEKINAH GLORY MINISTRY OF BATON ROUGE

Provider Business Mailing Address
First Line	:	PO BOX 53766
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70892-3766
Country	:	US
Telephone Number	:	225-924-4575
Fax Number	:	225-924-4574

Provider Business Practice Location Address
First Line	:	3613 GOVERNMENT ST
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-5721
Country	:	US
Telephone Number	:	225-346-5225
Fax Number	:	225-346-5225

Authorized Official
Title or Position	:	PASTOR
Name	:	MS. DEBRA DENISE CARTER
Credential	:
Telephone Number	:	225-924-4575

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	09/25/2007

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