Provider Demographics
NPI:1932308335
Name:CERTICARE, INC
Entity Type:Organization
Organization Name:CERTICARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:318-255-1077
Mailing Address - Street 1:413 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4654
Mailing Address - Country:US
Mailing Address - Phone:318-255-1077
Mailing Address - Fax:318-254-8250
Practice Address - Street 1:413 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-4654
Practice Address - Country:US
Practice Address - Phone:318-255-1077
Practice Address - Fax:318-254-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1462870Medicaid