Provider Demographics
NPI:1306827449
Name:JEFFERSON MANOR NURSING & REHAB CNTR LLC
Entity Type:Organization
Organization Name:JEFFERSON MANOR NURSING & REHAB CNTR LLC
Other - Org Name:JEFFERSON MANOR 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 1:9919 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2769
Mailing Address - Country:US
Mailing Address - Phone:225-293-1434
Mailing Address - Fax:225-291-3254
Practice Address - Street 1:9919 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2769
Practice Address - Country:US
Practice Address - Phone:225-293-1434
Practice Address - Fax:225-291-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA751314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1521213Medicaid
LA1521213Medicaid