Provider Demographics
NPI:1164641833
Name:HOLY ANGELS RESIDENTIAL FACILITY
Entity Type:Organization
Organization Name:HOLY ANGELS RESIDENTIAL FACILITY
Other - Org Name:SCOTTWOOD 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:318-797-8500
Mailing Address - Street 1:10450 ELLERBE ROAD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7712
Mailing Address - Country:US
Mailing Address - Phone:318-423-6685
Mailing Address - Fax:
Practice Address - Street 1:10450 ELLERBE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7712
Practice Address - Country:US
Practice Address - Phone:318-797-8500
Practice Address - Fax:318-798-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1725021Medicaid