Provider Demographics
NPI:1316129828
Name:PROMISE PRIDE ENTERPRISES, INC.
Entity type:Organization
Organization Name:PROMISE PRIDE ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:225-774-3385
Mailing Address - Street 1:5100 GROOM RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-3124
Mailing Address - Country:US
Mailing Address - Phone:225-774-3385
Mailing Address - Fax:225-774-7381
Practice Address - Street 1:5100 GROOM RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3124
Practice Address - Country:US
Practice Address - Phone:225-774-3385
Practice Address - Fax:225-774-7381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROMISE PRIDE ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAADHC 5039261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1191655Medicaid
IA1468070Other(WAIVER)