Provider Demographics
NPI:1124186937
Name:SOUTHERN OAKS NURSING & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN OAKS NURSING & REHABILITATION CENTER, LLC
Other - Org Name:SOUTHERN OAKS NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TEDDY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-628-4116
Mailing Address - Street 1:1524 GLEN OAK PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3816
Mailing Address - Country:US
Mailing Address - Phone:318-221-0911
Mailing Address - Fax:318-222-6333
Practice Address - Street 1:1524 GLEN OAK PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3816
Practice Address - Country:US
Practice Address - Phone:318-221-0911
Practice Address - Fax:318-222-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA93314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510394Medicaid
LA195558Medicare ID - Type UnspecifiedPROVIDER NUMBER