Provider Demographics
NPI:1912195355
Name:LASTING IMPRESSION CARE, INC
Entity Type:Organization
Organization Name:LASTING IMPRESSION CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRU'IESHIA
Authorized Official - Middle Name:RANEE
Authorized Official - Last Name:ANDERSON-MANARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-227-8343
Mailing Address - Street 1:405 GRETNA BLVD
Mailing Address - Street 2:SUITE 103C
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-4900
Mailing Address - Country:US
Mailing Address - Phone:504-227-8343
Mailing Address - Fax:504-227-8540
Practice Address - Street 1:405 GRETNA BLVD
Practice Address - Street 2:SUITE 103C
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-4900
Practice Address - Country:US
Practice Address - Phone:504-227-8343
Practice Address - Fax:504-227-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 14002320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1723100Medicaid