Organization
PROVINCIAL COMMUNITY HOME INC
Active
Other names
Pecan Grove 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
167 POOLE ROAD, MANSFIELD, LA 71052-5007
(318) 872-0206
(318) 872-8833
Mailing address
167 POOLE ROAD, MANSFIELD, LA 71052-5007
(318) 872-0206
(318) 872-8833
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
636
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1718971
—
LA
Enumeration date
05/23/2007
Last updated
08/22/2020
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