Provider Demographics
NPI:1770800724
Name:COMPANION CARE OF SWLA
Entity type:Organization
Organization Name:COMPANION CARE OF SWLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-463-3550
Mailing Address - Street 1:1014 N PINE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634
Mailing Address - Country:US
Mailing Address - Phone:337-463-3550
Mailing Address - Fax:337-463-8012
Practice Address - Street 1:1014 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634
Practice Address - Country:US
Practice Address - Phone:337-463-3550
Practice Address - Fax:337-463-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA15351253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care