Organization
IMMACULATE HEART OF MARY-PCS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BENNETT WADE MORAIN (OWNER)
(337) 623-4100
Entity
Organization
Contact information
Practice address
226 LYONS STREET, MELVILLE, LA 71353
(337) 623-4100
(337) 623-4102
Mailing address
P.O. BOX 670, MELVILLE, LA 71353-0670
(337) 623-4100
(337) 623-4102
Taxonomy
Speciality
Code
Description
License number
State
372500000X
Chore Provider
Primary
PCA 12145
LA
Other
Enumeration date
07/29/2011
Last updated
07/29/2011
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