Provider Demographics
NPI:1093905762
Name:PREMIER HOSPICE OF MANGHAM, LLC
Entity Type:Organization
Organization Name:PREMIER HOSPICE OF MANGHAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GOODWIN
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:318-281-0000
Mailing Address - Street 1:1523 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4043
Mailing Address - Country:US
Mailing Address - Phone:318-281-0000
Mailing Address - Fax:318-281-2753
Practice Address - Street 1:104-2 WEST BAYOU
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241
Practice Address - Country:US
Practice Address - Phone:318-281-0000
Practice Address - Fax:318-281-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATBD251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based