Provider Demographics
NPI:1659581379
Name:PROVINCIAL COMMUNITY HOME INC
Entity Type:Organization
Organization Name:PROVINCIAL COMMUNITY HOME INC
Other - Org Name:GIBBS STREET COMMUNITY HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-0206
Mailing Address - Street 1:416 GIBBS STREET
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2618
Mailing Address - Country:US
Mailing Address - Phone:318-872-6817
Mailing Address - Fax:318-872-8833
Practice Address - Street 1:416 GIBBS STREET
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2618
Practice Address - Country:US
Practice Address - Phone:318-872-6817
Practice Address - Fax:318-872-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA659315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1719323Medicaid