Provider Demographics
NPI:1376697664
Name:MERRYVILLE NURSING CENTER
Entity Type:Organization
Organization Name:MERRYVILLE NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-825-6181
Mailing Address - Street 1:900 N BRYAN ST
Mailing Address - Street 2:P.O. BOX 820
Mailing Address - City:MERRYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70653-3302
Mailing Address - Country:US
Mailing Address - Phone:337-825-6181
Mailing Address - Fax:337-825-2007
Practice Address - Street 1:900 N BRYAN ST
Practice Address - Street 2:
Practice Address - City:MERRYVILLE
Practice Address - State:LA
Practice Address - Zip Code:70653-3302
Practice Address - Country:US
Practice Address - Phone:337-825-6181
Practice Address - Fax:337-825-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA881313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510025Medicaid
LA1510025Medicaid