Provider Demographics
NPI:1669652855
Name:IMMACULATE HEART OF MARY-PCS LLC
Entity Type:Organization
Organization Name:IMMACULATE HEART OF MARY-PCS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-694-3312
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:MORGANZA
Mailing Address - State:LA
Mailing Address - Zip Code:70759-0505
Mailing Address - Country:US
Mailing Address - Phone:225-694-3312
Mailing Address - Fax:225-694-0337
Practice Address - Street 1:241 NORTH LA 1
Practice Address - Street 2:
Practice Address - City:MORGANZA
Practice Address - State:LA
Practice Address - Zip Code:70759
Practice Address - Country:US
Practice Address - Phone:225-694-3312
Practice Address - Fax:225-694-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1025739Medicaid