Basic Information
| Provider Information | |||||||||
| NPI: | 1689836488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERSONAL CARE SERVICES - WAIVER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6659 SULLIVAN RD | ||||||||
| Address2: | |||||||||
| City: | GREENWELL SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707393112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252610160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6659 SULLIVAN RD | ||||||||
| Address2: | |||||||||
| City: | GREENWELL SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707393112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252610160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | AUSTIN | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2252610160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PERSONAL CARE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | PCA 8370 | LA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1102733 | 05 | LA | MEDICAID |