Provider Demographics
NPI:1902080146
Name:ROYALTY PERSONAL CARE LLC
Entity type:Organization
Organization Name:ROYALTY PERSONAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-803-8217
Mailing Address - Street 1:1532 SOUTH BURNSIDE AVE.SUITE 10 A
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70707
Mailing Address - Country:US
Mailing Address - Phone:225-677-9769
Mailing Address - Fax:225-313-3488
Practice Address - Street 1:1532 S BURNSIDE AVE BLDG 10A
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4444
Practice Address - Country:US
Practice Address - Phone:225-677-9769
Practice Address - Fax:225-313-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 14063302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization