MEDICARE: MEMORIAL HOME AND COMMUNITY BASED WAIVER

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	251B00000X	Case Management Agency	PCA 14033	LA

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	:	1851569941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL HOME AND COMMUNITY BASED WAIVER

Provider Business Mailing Address
First Line	:	PO BOX 5610
Second Line	:
City	:	SLIDELL
State	:	LA
Zip	:	70469-5610
Country	:	US
Telephone Number	:	504-243-1018
Fax Number	:	504-243-1066

Provider Business Practice Location Address
First Line	:	5640 READ BLVD
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70127-3140
Country	:	US
Telephone Number	:	504-243-1018
Fax Number	:	504-243-1066

Authorized Official
Title or Position	:	CEO
Name	:	MARK ALLEN MORAD
Credential	:
Telephone Number	:	504-243-1018

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	08/06/2010

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Directions to “MEMORIAL HOME AND COMMUNITY BASED WAIVER ” Practice Location

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