Provider Demographics
NPI:1790801264
Name:LOUISE S DAVIS RESIDENTIAL FACILITIES, LLC
Entity Type:Organization
Organization Name:LOUISE S DAVIS RESIDENTIAL FACILITIES, LLC
Other - Org Name:DUNDEE COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-439-6600
Mailing Address - Street 1:1 LAKESHORE DR
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70629-0100
Mailing Address - Country:US
Mailing Address - Phone:337-439-6600
Mailing Address - Fax:337-439-6647
Practice Address - Street 1:2901 DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5807
Practice Address - Country:US
Practice Address - Phone:337-439-6600
Practice Address - Fax:337-439-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA969320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1718726Medicaid