Provider Demographics
NPI:1942376108
Name:ANGEL MANOR PCS LLC
Entity Type:Organization
Organization Name:ANGEL MANOR PCS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-232-7761
Mailing Address - Street 1:708 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6810
Mailing Address - Country:US
Mailing Address - Phone:337-232-7761
Mailing Address - Fax:337-232-7762
Practice Address - Street 1:708 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6810
Practice Address - Country:US
Practice Address - Phone:337-232-7761
Practice Address - Fax:337-232-7762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10343251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1178179Medicaid