Provider Demographics
NPI:1558576884
Name:ST. MARY ASSOCIATION FOR RETARDED CITIZENS
Entity Type:Organization
Organization Name:ST. MARY ASSOCIATION FOR RETARDED CITIZENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-836-9445
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70522-0003
Mailing Address - Country:US
Mailing Address - Phone:337-836-9445
Mailing Address - Fax:
Practice Address - Street 1:100 MISSOURI STREET
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:LA
Practice Address - Zip Code:70522
Practice Address - Country:US
Practice Address - Phone:337-836-9445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAADC2242251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1911135Medicaid