Organization
PROVIDENT FOUNDATION - WEDGEWOOD TERRACE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBRA W. LOCKWOOD (PRESIDENT & CHIEF FINANCIAL OFFICER)
(225) 766-3977
Entity
Organization
Contact information
Practice address
2114 VINEYARD AVENUE, LEWISTON, ID 83501
(208) 743-4545
(208) 743-2268
Mailing address
5565 BANKERS AVENUE, BATON ROUGE, LA 70808
(225) 766-3977
(225) 766-3988
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
—
—
311500000X
Alzheimer Center (Dementia Center)
—
—
385H00000X
Respite Care
—
—
Other
Enumeration date
06/07/2018
Last updated
06/07/2018
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