MEDICARE: FAMILY LIFE DEVELOPMENTAL CENTER

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	251C00000X	Developmentally Disabled Services Day Training Agency	7235	LA

General Provider Information

NPI Number	:	1568669679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY LIFE DEVELOPMENTAL CENTER

Provider Business Mailing Address
First Line	:	829 E GEORGIA AVE STE 5
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-3901
Country	:	US
Telephone Number	:	318-255-8405
Fax Number	:	318-255-8417

Provider Business Practice Location Address
First Line	:	829 E GEORGIA AVE STE 5
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-3901
Country	:	US
Telephone Number	:	318-255-8405
Fax Number	:	318-255-8417

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ALPHONSO BINGHAM
Credential	:
Telephone Number	:	318-255-8405

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	05/27/2008

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