Provider Demographics
NPI:1720006679
Name:MANGHAM HOME CARE INC
Entity Type:Organization
Organization Name:MANGHAM HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-248-2797
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:714 BROADWAY
Mailing Address - City:MANGHAM
Mailing Address - State:LA
Mailing Address - Zip Code:71259
Mailing Address - Country:US
Mailing Address - Phone:318-248-2797
Mailing Address - Fax:318-248-3536
Practice Address - Street 1:714 BROADWAY
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259
Practice Address - Country:US
Practice Address - Phone:318-248-2797
Practice Address - Fax:318-248-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA377251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1402818Medicaid
LA1402818Medicaid