Provider Demographics
NPI:1083722193
Name:SHANNONDALE OF ALEXANDRIA, INC.
Entity Type:Organization
Organization Name:SHANNONDALE OF ALEXANDRIA, INC.
Other - Org Name:REGENCY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NFA
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HATHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-8343
Mailing Address - Street 1:5131 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3366
Mailing Address - Country:US
Mailing Address - Phone:318-445-8343
Mailing Address - Fax:318-445-8527
Practice Address - Street 1:5131 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3366
Practice Address - Country:US
Practice Address - Phone:318-445-8343
Practice Address - Fax:318-445-8527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA456313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility