Provider Demographics
NPI:1144404054
Name:EXECTIONAL CLIENT CARE SERVICES
Entity Type:Organization
Organization Name:EXECTIONAL CLIENT CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-242-0041
Mailing Address - Street 1:919 N TRENTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3375
Mailing Address - Country:US
Mailing Address - Phone:318-242-0041
Mailing Address - Fax:318-513-1016
Practice Address - Street 1:919 N TRENTON ST STE 101
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3375
Practice Address - Country:US
Practice Address - Phone:318-242-0041
Practice Address - Fax:318-513-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 6660251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1706299Medicaid