Provider Demographics
NPI:1295228054
Name:PROVIDENT FOUNDATION - WEDGEWOOD TERRACE LLC
Entity Type:Organization
Organization Name:PROVIDENT FOUNDATION - WEDGEWOOD TERRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-3977
Mailing Address - Street 1:5565 BANKERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-766-3977
Mailing Address - Fax:225-766-3988
Practice Address - Street 1:2114 VINEYARD AVENUE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-4545
Practice Address - Fax:208-743-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No385H00000XRespite Care FacilityRespite Care