Provider Demographics
NPI:1306481445
Name:UPGRADE GROUP HOME LLC
Entity type:Organization
Organization Name:UPGRADE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF THEOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-394-9271
Mailing Address - Street 1:3719 KATHERINE AVE
Mailing Address - Street 2:3719 KATHERINE AVE
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805
Mailing Address - Country:US
Mailing Address - Phone:225-394-9271
Mailing Address - Fax:
Practice Address - Street 1:3719 KATHERINE AVE
Practice Address - Street 2:3719 KATHERINE AVE
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805
Practice Address - Country:US
Practice Address - Phone:225-394-9271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8017464Medicaid