Provider Demographics
NPI:1962661561
Name:HAVENS GATEWAY PERSONAL CARE FACILITY INC
Entity Type:Organization
Organization Name:HAVENS GATEWAY PERSONAL CARE FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALFREDA
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:225-343-4740
Mailing Address - Street 1:1200 S ACADIAN THRUWAY
Mailing Address - Street 2:212
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6900
Mailing Address - Country:US
Mailing Address - Phone:225-343-4740
Mailing Address - Fax:225-343-4742
Practice Address - Street 1:1200 S ACADIAN THRUWAY
Practice Address - Street 2:212
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6900
Practice Address - Country:US
Practice Address - Phone:225-343-4740
Practice Address - Fax:225-343-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 6770251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581895Medicaid