Provider Demographics
NPI:1336306653
Name:PROSPERITY'SHOUSECOMMUNITYSVS.INC.
Entity type:Organization
Organization Name:PROSPERITY'SHOUSECOMMUNITYSVS.INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PINKIE
Authorized Official - Middle Name:GRAYSON
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:BSINSOCIALWORK
Authorized Official - Phone:225-273-4013
Mailing Address - Street 1:514 TRAMMELL DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-6940
Mailing Address - Country:US
Mailing Address - Phone:225-273-4013
Mailing Address - Fax:225-273-4013
Practice Address - Street 1:514 TRAMMELL DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-6940
Practice Address - Country:US
Practice Address - Phone:225-273-4013
Practice Address - Fax:225-273-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11022320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11022Medicaid