Provider Demographics
NPI:1467630475
Name:CERTICARE,INC.
Entity Type:Organization
Organization Name:CERTICARE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:318-742-4510
Mailing Address - Street 1:3018 OLD MINDEN RD
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2446
Mailing Address - Country:US
Mailing Address - Phone:318-742-4510
Mailing Address - Fax:318-742-4096
Practice Address - Street 1:3018 OLD MINDEN RD
Practice Address - Street 2:SUITE 1110
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2446
Practice Address - Country:US
Practice Address - Phone:318-742-4510
Practice Address - Fax:318-742-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1029700Medicaid