MEDICARE: COMPANION CARE OF SWLA

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	253Z00000X	In Home Supportive Care Agency	PCA15305	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15305	OTHER	LA	PCA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467788976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPANION CARE OF SWLA

Provider Business Mailing Address
First Line	:	1014A N PINE ST
Second Line	:
City	:	DERIDDER
State	:	LA
Zip	:	70634-2818
Country	:	US
Telephone Number	:	337-463-3550
Fax Number	:	337-462-8012

Provider Business Practice Location Address
First Line	:	1014 N PINE ST
Second Line	:
City	:	DERIDDER
State	:	LA
Zip	:	70634-2818
Country	:	US
Telephone Number	:	337-463-3550
Fax Number	:	337-462-8012

Authorized Official
Title or Position	:	CHIEF ADMINISTRATOR
Name	:	MR. MARK RICHARD WALLACE
Credential	:	OWNER
Telephone Number	:	337-396-1899

Provider Enumeration Date	:	10/19/2009
Last Update Date	:	04/21/2010

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Directions to “COMPANION CARE OF SWLA ” Practice Location

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