Provincial Community Home Inc

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

License

636 Issued in LA

Legal business name

PROVINCIAL COMMUNITY HOME INC

Practice address

167 Poole Road
Mansfield, LA 71052-5007

Phone

(318) 872-0206

Fax

(318) 872-8833

NPI assigned

May 23, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Johnny Drew Terrell

Title

Administrator

Phone

(318) 872-0206

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Pecan Grove Community Home Other name

Tax ID family

Gibbs Street Community Home2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Provincial Community Home Inc

  • Intellectual Disabilities Intermediate Care Facility
  • Mansfield, LA
  • NPI 1659581379
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179878400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1780894477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "167 POOLE ROAD",
            "city": "MANSFIELD",
            "state": "LA",
            "postal_code": "710525007",
            "telephone_number": "318-872-0206",
            "fax_number": "318-872-8833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "167 POOLE ROAD",
            "city": "MANSFIELD",
            "state": "LA",
            "postal_code": "710525007",
            "telephone_number": "318-872-0206",
            "fax_number": "318-872-8833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVINCIAL COMMUNITY HOME INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-23",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "TERRELL",
        "authorized_official_first_name": "JOHNNY",
        "authorized_official_middle_name": "DREW",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "318-872-0206",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "LA",
            "license": "636",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1718971",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pecan Grove Community Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Sonya Parker Poole, LPC NCC NCSP
• Kimberly Pradia
• Lakimberly Pratt Edwards
• Shanda N Price
• Provincial Community Home Inc
• Martha Rambin, RN
• Anitrecia Raymond
• Fred G Rew, DDS
• Courtney Ruth Richmond, BS
• Amy Melton Robbins, OT

• Intellectual Disabilities Intermediate Care Facility in Mansfield, LA
• Providers in Mansfield, LA by specialty
• Intellectual Disabilities Intermediate Care Facility in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.