Organization
CERTICAREINC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL DWAINE DOUGLAS SR. (PRESIDEN)
(318) 255-1077
Entity
Organization
Contact information
Practice address
413 S FARMERVILLE ST, RUSTON, LA 71270-4654
(318) 255-1077
Mailing address
413 S FARMERVILLE ST, RUSTON, LA 71270-4654
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1123609
—
LA
05
—
1123625
—
LA
05
—
1462870
—
LA
05
—
1773212
—
LA
05
—
1773620
—
LA
05
—
1773662
—
LA
Enumeration date
12/08/2006
Last updated
08/22/2020
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