1720390495 NPI number — CENTER FOR PERSONAL DEVELOPMENT INC

Table of content: (NPI 1720390495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720390495 NPI number — CENTER FOR PERSONAL DEVELOPMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR PERSONAL DEVELOPMENT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720390495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4381
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71211-4381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-361-0590
Provider Business Mailing Address Fax Number:
318-600-4985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 SHERIDAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-5127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-361-0590
Provider Business Practice Location Address Fax Number:
318-600-4985
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
LORIA
Authorized Official Middle Name:
SHELA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
318-512-1257

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  27028 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1813311 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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