Provider Demographics
NPI:1467788976
Name:COMPANION CARE OF SWLA
Entity Type:Organization
Organization Name:COMPANION CARE OF SWLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:337-396-1899
Mailing Address - Street 1:1014A N PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2818
Mailing Address - Country:US
Mailing Address - Phone:337-463-3550
Mailing Address - Fax:337-462-8012
Practice Address - Street 1:1014 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2818
Practice Address - Country:US
Practice Address - Phone:337-463-3550
Practice Address - Fax:337-462-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA15305253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA15305OtherPCA
LAPCA 15351Medicaid