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NPI Code Detail

MEDICARE: CERTICARE INC

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
1320900000XIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

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

General Provider Information

NPI Number : 1578762977
Entity Type Code : Organization
Provider Name (Legal Business Name) : CERTICARE INC
Provider Business Mailing Address
First Line : 3018 OLD MINDEN RD STE 1110
Second Line :
City : BOSSIER CITY
State : LA
Zip : 71112-2446
Country : US
Telephone Number : 318-742-4510
Fax Number : 318-742-4096
Provider Business Practice Location Address
First Line : 413 S FARMERVILLE ST
Second Line :
City : RUSTON
State : LA
Zip : 71270-4654
Country : US
Telephone Number : 318-255-1077
Fax Number : 318-254-8250
Authorized Official
Title or Position : PRESIDENT
Name : MR. MICHAEL DOUGLAS SR.
Credential :
Telephone Number : 318-255-1077
Provider Enumeration Date : 07/16/2007
Last Update Date : 08/22/2020

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Directions to “CERTICARE INC ” Practice Location

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