Provider Demographics
NPI:1831477405
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:WADE
Authorized Official - Last Name:MORAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-623-4100
Mailing Address - Street 1:P.O. BOX 670
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71353-0670
Mailing Address - Country:US
Mailing Address - Phone:337-623-4100
Mailing Address - Fax:337-623-4102
Practice Address - Street 1:226 LYONS STREET
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:LA
Practice Address - Zip Code:71353
Practice Address - Country:US
Practice Address - Phone:337-623-4100
Practice Address - Fax:337-623-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 12145372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty