Provider Demographics
NPI:1033658893
Name:PMG OPCO-BOGALUSA LLC
Entity Type:Organization
Organization Name:PMG OPCO-BOGALUSA LLC
Other - Org Name:RESTHAVEN LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULWARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-658-9977
Mailing Address - Street 1:1301 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-1700
Mailing Address - Country:US
Mailing Address - Phone:985-732-3909
Mailing Address - Fax:
Practice Address - Street 1:1301 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-1700
Practice Address - Country:US
Practice Address - Phone:985-732-3909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility