Provider Demographics
NPI:1568681914
Name:COLUMBIA DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:COLUMBIA DEVELOPMENTAL CENTER
Other - Org Name:PINEBURR COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ASSOCIATE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-649-6097
Mailing Address - Street 1:132 HIGHWAY 850
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-1559
Mailing Address - Country:US
Mailing Address - Phone:318-649-6097
Mailing Address - Fax:318-649-2868
Practice Address - Street 1:103 PINEBURR DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-4766
Practice Address - Country:US
Practice Address - Phone:318-649-6097
Practice Address - Fax:318-649-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA655320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1712248Medicaid