Basic Information
| Provider Information | |||||||||
| NPI: | 1295833713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOMER MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLAIBORNE MEMORIAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 620 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710403202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189273158 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710403202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189273158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COPELAND | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CNO | ||||||||
| AuthorizedOfficialTelephone: | 3189272024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOMER MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 1705802 | 05 | LA | MEDICAID |