Provider Demographics
NPI:1518090943
Name:E D & J GROUP HOME
Entity Type:Organization
Organization Name:E D & J GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:DISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-272-0269
Mailing Address - Street 1:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:VIOLET
Mailing Address - State:LA
Mailing Address - Zip Code:70092-0657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5602 6TH ST
Practice Address - Street 2:
Practice Address - City:VIOLET
Practice Address - State:LA
Practice Address - Zip Code:70092-3039
Practice Address - Country:US
Practice Address - Phone:504-272-0269
Practice Address - Fax:504-272-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1597538Medicaid