Basic Information
| Provider Information | |||||||||
| NPI: | 1255373031 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNDATION ANCILLARY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17617 S HARRELLS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257513685 | ||||||||
| FaxNumber: | 2257530948 | ||||||||
| Practice Location | |||||||||
| Address1: | 17617 S HARRELLS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257513685 | ||||||||
| FaxNumber: | 2257530948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | PITTMAN | ||||||||
| AuthorizedOfficialFirstName: | CINDIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICES | ||||||||
| AuthorizedOfficialTelephone: | 2257513685 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 03632301 | 05 | MS | MEDICAID | 1018334880001 | 05 | PA | MEDICAID | 1454214 | 05 | LA | MEDICAID |