Provider Demographics
NPI:1780827717
Name:ASSURED MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ASSURED MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-654-5871
Mailing Address - Street 1:139 JAMES COMEAUX RD STE B
Mailing Address - Street 2:NO 575
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3376
Mailing Address - Country:US
Mailing Address - Phone:337-654-5871
Mailing Address - Fax:122-520-8141
Practice Address - Street 1:200 AMERICAN LEGION DR
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-5826
Practice Address - Country:US
Practice Address - Phone:337-654-5871
Practice Address - Fax:225-208-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 15206253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA70 EPSDTMedicaid
LA03 CHILDREN CHOICEMedicaid
LA89 SIL WAIVERMedicaid
LA73 SOCIAL WORKERMedicaid
LA82 PCA WAIVERMedicaid
LA06 NOW PROFESSIONALMedicaid
LA24 PERSONAL CARE SERMedicaid