Provider Demographics
NPI:1104140565
Name:PRISM II, LLC
Entity type:Organization
Organization Name:PRISM II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENVENU
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:318-481-2148
Mailing Address - Street 1:740 KEYSER AVE
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6037
Mailing Address - Country:US
Mailing Address - Phone:318-214-0088
Mailing Address - Fax:318-214-9009
Practice Address - Street 1:740 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6037
Practice Address - Country:US
Practice Address - Phone:318-214-0088
Practice Address - Fax:318-214-9009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1362630Medicaid
LA1524069Medicaid
LA194545Medicare PIN
LA1524069Medicaid