Provider Demographics
NPI:1346463767
Name:CARROLL NURSING HOME
Entity Type:Organization
Organization Name:CARROLL NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:COX
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-428-3249
Mailing Address - Street 1:PO BOX 13524
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-3524
Mailing Address - Country:US
Mailing Address - Phone:800-815-0586
Mailing Address - Fax:318-445-9433
Practice Address - Street 1:307 N CASTLEMAN STREET
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263
Practice Address - Country:US
Practice Address - Phone:318-428-3249
Practice Address - Fax:318-428-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA165332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1549304Medicaid
LAF3410OtherBLUE CROSS BLUE SHIELD
LA1549304Medicaid