MEDICARE: CERTICARE, INC.

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

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	:	1457537169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CERTICARE, INC.

Provider Business Mailing Address
First Line	:	107 WEST ALABAMA AVE
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270
Country	:	US
Telephone Number	:	318-255-1077
Fax Number	:	318-254-8250

Provider Business Practice Location Address
First Line	:	3018 OLD MINDEN RD
Second Line	:	1110
City	:	BOSSIER CITY
State	:	LA
Zip	:	71112-2446
Country	:	US
Telephone Number	:	318-742-4510
Fax Number	:	318-742-4096

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. MICHAEL D DOUGLAS SR.
Credential	:
Telephone Number	:	318-255-1077

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	02/06/2008

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Directions to “CERTICARE, INC. ” Practice Location

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