Provider Demographics
NPI:1235110438
Name:GARDEN PARK NURSING & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:GARDEN PARK NURSING & REHABILITATION CENTER, LLC
Other - Org Name:GARDEN PARK NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
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:PO BOX 6479
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-6479
Mailing Address - Country:US
Mailing Address - Phone:318-688-0961
Mailing Address - Fax:318-686-9287
Practice Address - Street 1:9111 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6509
Practice Address - Country:US
Practice Address - Phone:318-688-0961
Practice Address - Fax:318-686-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA398314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1517798Medicaid
LA195248Medicare ID - Type Unspecified