Provider Demographics
NPI:1003074824
Name:FAMILY LIFE DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:FAMILY LIFE DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALPHONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:BINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-255-8405
Mailing Address - Street 1:829 E GEORGIA AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3901
Mailing Address - Country:US
Mailing Address - Phone:318-255-8405
Mailing Address - Fax:
Practice Address - Street 1:829 E GEORGIA AVE STE 5
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3901
Practice Address - Country:US
Practice Address - Phone:318-255-8405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1008958Medicaid