Provider Demographics
NPI:1851569941
Name:MEMORIAL HOME AND COMMUNITY BASED WAIVER
Entity Type:Organization
Organization Name:MEMORIAL HOME AND COMMUNITY BASED WAIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MORAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-243-1018
Mailing Address - Street 1:PO BOX 5610
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70469-5610
Mailing Address - Country:US
Mailing Address - Phone:504-243-1018
Mailing Address - Fax:504-243-1066
Practice Address - Street 1:5640 READ BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-3140
Practice Address - Country:US
Practice Address - Phone:504-243-1018
Practice Address - Fax:504-243-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 14033251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAPPLIED FORMedicaid