Provider Demographics
NPI:1639383367
Name:ACTIVE ADULT DAY HEALTHCARE LLC
Entity Type:Organization
Organization Name:ACTIVE ADULT DAY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:NJOKI
Authorized Official - Last Name:MWAKITAWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-948-9067
Mailing Address - Street 1:333 E PRUDHOMME ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6490
Mailing Address - Country:US
Mailing Address - Phone:337-948-9067
Mailing Address - Fax:337-948-9064
Practice Address - Street 1:333 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6490
Practice Address - Country:US
Practice Address - Phone:337-948-9067
Practice Address - Fax:337-948-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1721468Medicaid