Provider Demographics
NPI:1124081831
Name:MID- STATE HOME HEALTH AGENCY INC
Entity type:Organization
Organization Name:MID- STATE HOME HEALTH AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:318-443-9739
Mailing Address - Street 1:710 VERSAILLES BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2351
Mailing Address - Country:US
Mailing Address - Phone:318-443-9739
Mailing Address - Fax:318-443-9811
Practice Address - Street 1:710 VERSAILLES BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2351
Practice Address - Country:US
Practice Address - Phone:318-443-9739
Practice Address - Fax:318-443-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA354251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1402656Medicaid
LA1402656Medicaid