MEDICARE: BOYS AND GIRLS VILLAGES FOUNDATION

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	320800000X	Mental Illness Community Based Residential Treatment Facility	8998	LA

General Provider Information

NPI Number	:	1578822177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYS AND GIRLS VILLAGES FOUNDATION

Provider Business Mailing Address
First Line	:	7378 HIGHWAY 90 E
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-4803
Country	:	US
Telephone Number	:	337-436-7553
Fax Number	:	337-436-8291

Provider Business Practice Location Address
First Line	:	7378 HIGHWAY 90 E
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-4803
Country	:	US
Telephone Number	:	337-436-7553
Fax Number	:	337-436-8291

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MAYANCE JOSEPH MATHIEU, JR.
Credential	:	LPC
Telephone Number	:	337-436-7553

Provider Enumeration Date	:	05/16/2012
Last Update Date	:	05/16/2012

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