Provider Demographics
NPI:1699109983
Name:PROVISIONS CARE AND RESIDENTIAL SERVICES, LLC
Entity type:Organization
Organization Name:PROVISIONS CARE AND RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MINOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-775-8188
Mailing Address - Street 1:7125 VILLERE DR
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-5347
Mailing Address - Country:US
Mailing Address - Phone:225-775-8188
Mailing Address - Fax:225-775-8189
Practice Address - Street 1:7125 VILLERE DR
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-5347
Practice Address - Country:US
Practice Address - Phone:225-775-8188
Practice Address - Fax:225-775-8189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness