Provider Demographics
NPI:1821241712
Name:MELBROOK COMMUNITY HOME
Entity Type:Organization
Organization Name:MELBROOK COMMUNITY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCILWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-366-1828
Mailing Address - Street 1:PO BOX 6987
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70174-6987
Mailing Address - Country:US
Mailing Address - Phone:504-366-1828
Mailing Address - Fax:504-366-1867
Practice Address - Street 1:336 MELBROOK DR
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7715
Practice Address - Country:US
Practice Address - Phone:504-366-1828
Practice Address - Fax:504-366-1867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS LOUISIANA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1718289Medicaid
LA1719684Medicaid
LA1910074Medicaid
LA1918571Medicaid
LA1454257Medicaid
LA1718378Medicaid
LA1719595Medicaid