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Organization
PROVINCIAL COMMUNITY HOME INC
Active
Organization
PROVINCIAL COMMUNITY HOME INC
Active
Other names
Gibbs Street Community Home
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHNNY DREW TERRELL (ADMINISTRATOR)
(318) 872-0206
Entity
Organization
Contact information
Practice address
416 GIBBS STREET, MANSFIELD, LA 71052-2618
(318) 872-6817
(318) 872-8833
Mailing address
416 GIBBS STREET, MANSFIELD, LA 71052-2618
(318) 872-6817
(318) 872-8833
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
659
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1719323
—
LA
Enumeration date
05/23/2007
Last updated
08/22/2020
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