Provider Demographics
NPI:1609177757
Name:PEACH COMMUNITY HOME
Entity Type:Organization
Organization Name:PEACH COMMUNITY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:BERTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-448-0291
Mailing Address - Street 1:528 BOB WHITE LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2415
Mailing Address - Country:US
Mailing Address - Phone:318-787-6915
Mailing Address - Fax:
Practice Address - Street 1:528 BOB WHITE LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2415
Practice Address - Country:US
Practice Address - Phone:318-787-6915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16667320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities