Provider Demographics
NPI:1063454338
Name:PILGRIM MANOR GUEST CARE CENTER, LLC
Entity Type:Organization
Organization Name:PILGRIM MANOR GUEST CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-2648
Mailing Address - Street 1:PO BOX 52389
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2389
Mailing Address - Country:US
Mailing Address - Phone:318-798-2648
Mailing Address - Fax:318-798-3451
Practice Address - Street 1:1524 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3322
Practice Address - Country:US
Practice Address - Phone:318-742-1623
Practice Address - Fax:318-742-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA873314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510696Medicaid
LA1510696Medicaid