Provider Demographics
NPI:1235329061
Name:GIFTED HEART SERVICES, LLC
Entity Type:Organization
Organization Name:GIFTED HEART SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-394-1799
Mailing Address - Street 1:717 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARTINVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70582-4124
Mailing Address - Country:US
Mailing Address - Phone:337-394-1799
Mailing Address - Fax:337-394-1799
Practice Address - Street 1:717 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-4124
Practice Address - Country:US
Practice Address - Phone:337-394-1799
Practice Address - Fax:337-394-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11451251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1157848Medicaid